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MENTAL    DISEASES 


%i6t  of  tbis  Series 


MINOR    SURGERY  (JVew  and  Enlarged  Edition) 
By  L.  A.  BiDWELL,  F.R.C.S. 

TREATMENT   AFTER   OPERATION 

By  William  Turner,  F.R.C.S.,  and  E.   Rock 
Carling,  F.R.C.S. 

THE   MEDICAL   DISEASES 
OF   CHILDREN 
By  T.  R.  C.  Whipham,  j\I.D. 

THE   DISEASES  OF  THE   SKIN 
By  WiLLMOTT  Evans,  F.R.C.S. 

DISEASES   OF   THE    EYES 

By  C.  Devereux  Marshall,  F.R.C.S. 

DISEASES   OF   WOMEN 

ByT.  G.  Stevens,  M.D.,  F.R.C.S. 

DISEASES   OF  THE   EAR,   NOSE, 
AND   THROAT 

By  G.  N.  Biggs,  M.B. 

ANESTHESIA  AND   ANALGESIA 
By  J.  D.  Mortimer,  M.B.,  F.R.C.S. 

APPLIED    PATHOLOGY 

In  Diagnosis  and  Treatment. 
By  Julius  Bernstein,  M.B.,  M.R.C.P. 

THE  PRINCIPLES  AND  PRACTICE  OF 
MEDICAL   HYDROLOGY 
By  R.   FoRTESCUE  Fox,  M.D. 

MENTAL   DISEASES 

By  R.  H.  Cole,  I\I.D.,  M.R.C.P. 


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MENTAL  DISEASES 

A   TEXT-BOOK   OF    PSYCHIATRY   FOR 

MEDICAL    STUDENTS    AND 

PRACTITIONERS 


BY 


R.  H.  COLE,  M.D.  (Lond.),  M.R.C.P. 

PHYSICIAN   FOR    MENTAL    DISEASES   TO   ST.    MARY'S    HOSPITAL  ;    LECTURER 

ON   MENTAL    DISEASES  AT   ST.    MARV's    HOSPITAL   MEDICAL 

SCHOOL,    AND   AT  THE   WEST   LONDON   HOSPITAL 

POSTGRADUATE   COLLEGE 


WITH  FIFTY-TWO   ILLUSTRATIONS  AND  PLATES 


NEW  YORK 

WILLIAM    WOOD   &    CO. 


First  Edition,  Novemier  1913 


PREFACE 

Ijsf  this  volume  I  have  endeavoured  to  dehneate  the  salient 
features  of  our  present  knowledge  of  Psychiatry  in  as  concise 
a  manner  as  possible.  It  has  been  my  aim  to  treat  the  subject 
from  a  general  standpoint,  without  unduly  obtruding  my  own 
particular  experience  of  asylum  and  hospital  practice.  Current 
Hterature  has  been  freely  consulted,  and  the  latest  develop- 
ments in  the  Psychology  and  Pathology  of  Insanity  have 
received  attention. 

The  pathological  illustrations  are  from  original  drawings 
by  Miss  A.  M.  Kelley.  They  have  been  made  almost  entirely 
from  specimens  at  the  Claybury  Laboratory,  by  the  kind 
permission  of  Dr.  Mott,  whose  never-failing  readiness  to  en- 
courage and  assist  others  in  their  work  is  well  known.  The 
clinical  pictures  are  from  photographs  taken  by  Dr.  W.  E. 
Collier,  of  the  Maidstone  Asylum,  to  whom  I  desire  to  express 
my  obhgation. 

A  few  explanatory  charts  and  diagrams  have  been  added, 
and  some  elementary  reference  has  been  made  to  the  structure 
and  vascular  supply  of  the  Organ  of  Mind,  as  such  details  I 
find  are  apt  to  be  forgotten  in  the  routine  of  clinical  work. 
The  description  of  the  individual  psychoses  has  been  somewhat 
condensed,  as  I  feel  that  further  knowledge  of  them  can  best  be 
acquired  from  practical  demonstrations.  Incorporated  in  the 
Legal  Chapter  are  the  main  provisions  of  the  Mental  Deficiency 
Act.  In  addition  to  a  special  chapter  on  Treatment  there  is  a 
brief  account  of  Prognosis  which  I  hope  may  prove  useful. 

I  wish  to  express  my  indebtedness  to  Dr.  J.  A.  Perdrau  for 
revising  and  correcting  the  text  and  for  making  many  sugges- 
tions and  criticisms.  I  have  also  to  thank  Dr.  Ralph  Brown, 
of  Bethlem  Royal  Hospital,  for  reading  the  proof-sheets. 


CONTENTS 

CHAP.  PAGE 

I  Insanity,  its  Incidence  and  History     ...  1 

II  Mind,  Consciousness,  Sleep,  Memory    ...  13 

III  Sensation,  Perception,  and  Ideation  (Cognition)  .  31 

IV  Feeling,  Emotion,  and  Sentiment  (Affection)      .  47 
V  Instinct,  Volition,  and  x\ttention  (Conation)       .  55 

VI     The  Diagnosis  of  Insanity 71 

VII     General  Causation  .......      84 

VIII     Classification 99 

IX    Maniacal-Depressive  Insanity         ....     105 

Melancholia  (Intermittent). 
Mania  ,, 

Alternating  (Periodic). 

X     Confusional  Insanity 125 

Acute  Confusional. 
Acute  Delirium. 
Stupor. 

XI    Paranoia  (Systematised  Delusional  Insanity)       .     136 

XII     Amentia 142 

Idiocy,  and  Imbecility. 
Congenital  Feeble-mindedness. 
Moral  Degeneracy. 

XIII    Dementia 156 

Primary,  or  Dementia  Prtecox, 
Secondary,  Organic,  and  Senile, 
vii 


viii  CONTENTS 

CHAP.  PAGE 

XIV     General  Paralysis  (Dementia  Paralytica)    .         .171 
XV    Alcohol  and  Insanity 186 

ilorphinism  and  other  Drug  Insanities. 

XVI     Childbirth  and  Insanity 201 

The  Epochs  of  Life  and  Insanity. 

XVII     Epilepsy  and  Insanity 209 

XVIII     Hysteria,      Neurasthenia,      Psychasthenia,     and 

Insanity  .         .         .         .         .         .         .         .     216 

XIX     General  Diseases  and  Insanity      ....     226 
Traumatism  and  Insanity. 

XX     The  Pathology  of  Insanity 235 

XXI     The  Elements  of  Prognosis 256 

XXII     The    Legal   Eelations   of   Insanity  and   Mental 

Deficiency 262 

Certification  for  Care  and  Treatment . 
Testamentary  Capacity. 
Civil  Liability. 
Criminal  Eesponsibility. 

XXIII     General  Treatment 286 

Preventive,  Curative. 

The  Care  of  the  Chronic  Insane  and  Mental  Defectives. 

APPENDIX 

Eeception  Forms      .        .         .         .         .         ,         .     322 

Index 335 


LIST   OF   ILLUSTRATIONS 


1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 
10. 
U. 
12. 

13. 

14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 


Right  hemisphere  from  a  case  of  general  paralysis  .     {Frontispiece) 

Chart  showing  the  excess  of  admissions  over  discharges  and  deaths 

of  the  certified  insane  in  England  and  Wales  from  1901  to  1911  5 

The  old  system  of  treatment    ........  9 

A  modern  method  of  treatment        .......  12 

Dualism  and  monism         .........  15 

Graphic  representation  of  mind        .......  17 


Curve  illustrating  intensity  or  quality  of  sleep  .... 

Chart  showing  daily  amount  of  sleep        ...... 

The  neuron  (Golgi's  silver  stain  x  60)      ...... 

Diagram  showing  synapses       .         .         .         .         .         .         ... 

The  normal  nerve  cell  (Nissl  x  400)         .         .         .       Plate  facing 

Strip   of    normal   motor   cortex,   showing  nerve  fibres  (Weigert- 
Pal  X  45)    . Plate  facing 

Strip  of  laormal  motor  cortex,   showing  nerve  cells   (Nissl  x  45) 

plate  faxing 

The  association  fibres  of  the  cerebrum 

Cerebral  localisation,  external  surface 

Cerebral  localisation,  mesial  surface 

The  language  mechanism — speech  and  writing 

Handwriting  in  the  insane 

Diagram  of  mental  processes    . 

Acute  melancholia    . 

Group  of  chronic  melancholiacs 

Acute  mania     .... 

Chronic  mania 

Diagram  of  alternating  insanity 

Acute  confusional  insanity 

Genetous  idiocy 

Group  of  microcephalic  idiots  in  one  family 

Epileptic  idiocy 

Cretinism  .... 

Dementia  Preecox  (Katatonia) 

Dementia  Prsecox  (flexibilitas  cerea) 


19 
21 
22 

23 
24 

25 

25 

26 

27 

27 

64 

66 

69 

106 

109 

116 

119 

124 

127 

143 

145 

146 

148 

159 

161 


X 


FIG. 


LIST   OF  ILLUSTRATIONS 


PAGE 


32.  Group  of  general  paralytics 174 

33.  Unequal  pupils  in  general  paralysis  .         .         .         .         .         .  175 

34.  The  third  stage  of  general  paralysis 179 

35.  Scars  in  epilepsy 213 

36.  MyxcBdema 231 

37.  Hemisphere  in  dementia 238 

38.  Brain  in  prof ound 'amentia 239 

39.  Diagrammatic    strip    of    cortex  :    (a)    normal ;    (6)    amentia ;    (c) 

dementia 240 

40.  Strip  of  motor  cortex  in  general  paralysis,  showing  loss  of  nerve 

fibres  and  increase  of  capillaries  (Weigert-Pal  X  45)    Plate  facing  241 

41.  Strip  of  motor  cortex  in  general  paralysis,  showing  degeneration  of 

nerve  cells  and  perivascular  infiltration  (Nissl  x  45)    Plate  facing  241 

42.  Stages  of  degeneration  in  nerve  cells,  showing  also  phagocytosis 

(Nissl  X  400) Plate  facing  242 

43.  Plasma   cells  ;    rod   cells  ;    glia   cells   (Nissl   and   Weigert  x  500) 

Plate  facing  244 

44.  Granulations    on   floor   of    fourth    ventricle    (semi-diagrammatic) 

Plate  facing  244 

45.  Film  of  cerebro-spinal  fluid  in  general  paralysis,  showdng  lympho- 

cytosis ( x  250)   Plate  facing  246 

46.  Diagram  of  the  arteries  of  the  brain 247 

47.  Diagram  of  the  venous  sinuses  of  the  brain 248 

48.  Perivascular  infiltration  (Nissl  x  300)       .         .         .      Plate  facing  250 

49.  Proliferating    capillaries ;    also    plasma     and     endothelial     cells 

(Nissl  x  300) Plate  facing  250 

50.  The  V-shaped  palate 253 

51.  Abnormalities  of  the  ear 254 

52.  Hematoma  auris      ..........  255 


MENTAL    DISEASES 

CHAPTER   I 
INSANITY,    ITS    INCIDENCE    AND    HISTORY 

In  this  preliminary  chapter,  which  is  a  broad  survey  of  the 
subject,  it  is  proposed,  firstl}',  to  acquaint  the  student  mth 
some  facts  as  to  the  prevalence  of  mental  diseases,  and  to 
discuss  what  qualification  is  necessar}"  before  accepting  the 
commonh"  expressed  statement  that  insanity  is  increasing  in 
our  midst ;  secondly,  to  give  a  brief  sketch  of  some  of  the 
historical  records  concerning  mental  diseases,  and  to  trace  the 
evolution  of  our  ideas  regarding  insanity  and  its  treatment. 
These  matters  do  not  perhaps  belong  to  the  scientific  investi- 
gation of  psychiatry,  but  nevertheless  they  are  of  interest  and 
importance,  and  should  receive  the  student's  attention. 

Sex. — Both  sexes  are  about  equally  Hable  to  insanit}', 
although  the  etiology  in  each  sex  varies  to  some  extent.  In 
cases  newly  admitted  to  asj'lums  the  ratio  of  females  to  males 
is  as  18  :  17,  which  is  approximately  the  same  as  that  in  the 
general  population.  In  the  latter,  although  more  males  are 
born,  the  death-rate  among  them  especially  in  early  years  is 
greater,  so  that  females  predominate.  In  asylums,  however, 
the  ratio  of  the  female  to  the  male  sex  tends  to  be  slightly 
further  increased,  being  as  19  :  17,  which  is  mostly  due  to 
the  fact  of  that  fatal  disease  General  Parah^sis  attacking 
men  more  frequently  than  women. 

Age. — Lisanity  affects  all  ages,  but  is  mostl}'  developed  in 
middle  life,  as  might  be  expected.  In  children  it  is  chiefly  the 
result  of  arrested  mental  development. 

Civil  State. — The  single  and  Tvddowed  states  greatly  pre- 
ponderate over  the  married  state,  being  in  a  proportion  of  more 
than  2:1.  This  is  partly  due  to  a  law  of  Nature  by  which 
B  "^1 


2  MENTAL  DISEASES 

abnormals  do  not  tend  to  procreate,  and  it  must  be  remembered 
that  the  sohtary  state  is  conducive  to  insanity. 

Civilisation. — Insanity  affects  all  races — Western  and 
Eastern,  white  and  black,  civilised  and  uncivihsed,  those  who 
work  and  those  who  are  idle,  those  who  are  rich  and  those  who 
are  poor,  those  who  are  religious  and  those  who  are  not. 

When  travelling  abroad,  the  student  should  not  lose  any 
opportunity  of  visiting  foreign  asylums,  where  he  will  notice 
how  insanity  differs  according  to  racial  type.  To  some  extent, 
however  paradoxical  it  may  seem,  insanity  must  be  regarded 
as  an  index  of  civilisation.  Where  specialisation  and  culture 
exist,  natural  variations,  normal  and  morbid,  become  more 
evident.  Amongst  savages  the  grosser  forms  of  mental  weak- 
ness are  chiefly  exhibited,  such  as  idiocy  and  imbecilitj^,  but 
even  these  failures  of  development  are  stamped  out  by  the 
inexorable  laws  of  Nature,  by  which  the  fittest  alone  survive. 
Moreover,  the  growth  of  altruism  in  primitive  tribes  is  but 
feebly  established,  so  that  those  members,  who  by  reason  of 
age  or  infirmity  of  mind  or  body  are  unable  to  assist  in  the 
common  weal,  get  neglected  and  are  apt  to  come  to  an  untimely 
end.  Added  to  this  is  the  effect  of  superstitions,  by  which  the 
diseased  and  afflicted  not  infrequently  are  put  to  death,  so 
that  insanity  and  disease  are  not  common  in  such  rude  con- 
ditions of  existence.  As  civihsation  has  spread,  and  life  has 
become  more  complex,  mental  variations  have  become  more 
apparent.  These  not  only  embrace  the  insane,  but  also  those 
who,  being  endowed  above  the  common  herd,  fail  to  develop 
further  for  lack  of  opportunity.  Even  in  civilised  nations 
some  people  become  dull-witted  and  mentally  disordered, 
in  rural  districts,  from  want  of  appropriate  stimuli.  Yet 
more  frequently  others  succumb  from  that  excessive  stimula- 
tion, which  is  apt  to  follow  in  the  path  of  civilisation  in  general. 
Looking  backward,  it  would  seem  as  if  civihsation  itself  in  time 
brings  about  its  own  destruction.  A  nation  which  has  been 
pre-eminent  declines  owing  to  a  failure  of  innate  vitaht}^  and 
the  lessons  to  be  learnt  from  it  are  that  luxury  and  excesses 
or  disobedience  to  Nature's  laws,  lead  inevitably  to  a  nation's 
doom. 

Thus  in  our  own  time  there  is  a  searching  inquiry  into  our 
conditions  of  existence  and  methods  of  life,  in  which  extreme 


INSANITY,   ITS   INCIDENCE   AND   HISTORY        3 

views  have  been  expressed  b}'  some  authorities.  ^\jiiougst  them 
are  those  who  preach  that  our  race  is  degenerating  at  no 
uncertain  rate,  as  evidenced  by  the  amount  of  pauperism,  of 
criminaht}",  and  of  mental  and  phj^sical  deficienc3%  amongst  us  ; 
and  that  to  stay  the  process  of  general  deterioration,  radical 
Eugenic  principles  should  be  carried  into  effect,  in  the  place 
of  the  present  sj^stem  of  segregation.  Too  often,  however,  is  it 
lost  sight  of,  that  the  bulk  of  the  average  stock  is  sound  enough, 
and  that  men  of  talent,  and  even  of  genius,  continue  to  flourish 
as  heretofore.  True  it  is,  that,  in  spite  of  modern  methods 
of  research,  the  recovery  rate  of  insanity  shows  no  material 
reduction ;  yet  the  statistics  of  our  asj'lums  need  not  paralyse 
our  perspective  altogether.  The  cost  of  insanity  is  indeed  a 
burden  that  has  to  be  borne,  the  yearly  upkeep  of  our  pauper 
asylums  costing  upwards  of  three  millions  sterling — apart  from 
capital  expenditure — yet  Humanit}'  teaches  us  that  this  is 
better  than  alloTidng  those  who  are  mentally  defective  or 
insane  to  roam  about,  imcared  for,  as  in  the  past. 

The  Alleged  Increase  of  Insanity. — There  is  no  satis- 
factory means  of  gauging  the  ratio  of  m.ental  disease  in  the 
community,  for  there  is  no  reliable  information  as  to  the 
numbers  of  the  uncertified  insane.  Confining  our  attention  to 
the  certified  insane,  it  cannot  be  denied  that  their  numbers 
increase  year  by  year,  and  that  in  a  decade  the  jDercentage 
increase  is  double  that  of  the  general  population. 

To  compare  figures  roughh' :  At  the  last  census,  in  1911, 
the  population  of  England  and  Wales  stood  at  36  millions — 
and  at  the  previous  census  in  1901  at  32|  millions — showing 
a  satisfactory  increase  in  the  decade  of  3|  millions,  or  10|%. 
The  annual  returns  of  the  certified  insane  for  those  j^ars  show 
for  1911 — 133,157  as  compared  with  107,944  for  1901,  or  an 
increase  of  about  23%. 

Without  unduly  decrying  the  amount  of  this  increase,  for 
which  many  explanations  are  forthcoming,  one  is  compelled 
to  make  the  remark  that,  after  all,  these  numbers  are  small 
in  comparison  A\dth  the  millions  of  our  population — considering 
that  there  are  267  sane  persons  to  ever}'  indi^-idual  who  is 
certified  as  insane  ! 

\ATien  the  uncertified  mentally  deficient — the  number  of  whom 
is  estimated  at  about  the  same  number  as  the  certified  insane — 


4  MENTAL   DISEASES 

are  segregated  from  the  general  population  and  are  added  to 
the  total,  a  further  state  of  alarm  will  no  doubt  be  created. 

Of  the  causes  that  lead  to  increased  registration  of  the 
insane,  involving  the  accumulation  of  insane  persons,  it  cannot 
be  denied  that  the  increased  popularity  of  institutions  is  one 
of  the  most  important.  Mild  mental  cases,  and  manj^  old 
people  are  sent  away  now  to  asylums,  that  were  formerly 
kept  at  home,  or  housed  in  the  workhouse  infirmaries.  The 
four-shilling  grant  from  the  Central  Exchequer  to  the  Guardians 
for  asylum  care  has  also  helped  in  tliis  direction.  The  statis- 
tics, it  must  be  remembered,  are  made  up  of  insane  persons, 
more  than  90%  of  whom  are  paupers,  who,  when  they  improve, 
have  not  the  outside  means  of  supervision  that  obtain  with  the 
private  class,  and  are  therefore  not  so  readily  discharged. 
When  the  figures  relating  to  the  private  class  are  examined, 
there  is  but  slight  increase  of  insanity  in  this  class.  If  any  undue 
influences  causing  an  increase  in  insanity  were  in  existence,  they 
should  show  themselves  quite  as  conspicuously  in  private 
patients  as  in  pauper  patients.  It  is  satisfactory  to  note  that 
during  the  last  few  years  the  total  admission  rate  to  the  ranks  of 
insanit}"  has  fallen  slighth',  as  the  accompanying  chart  (Fig.  2) 
illustrates 

x4nnual  Admissions  are  about 22,000 

Annual  Discharges  recovered 8,000 

Annual  Discharges  relieved  or  not  unproved  .  .    2,000 

Annual  Deaths 10,000 

20,000 

Leaving  a  yearly  surplus  of       2,000 

— which  if  the  odd  figures  were  reckoned  would  approximate  to 
2500  (2%  of  the  whole)  to  be  added  annually  to  the  130,000  to 
140,000  to  which  the  sum-total  of  insanity  is  now  reaching. 

Transfers  in  single  care,  or  from  one  institution  to  another, 
which  number  nearly  3500  annually,  do  not  of  course  affect  the 
figures.  The  recovery  rate  is  33%  of  the  admission  rate;  of 
patients  discharged  recovered  unfortunately  at  least  one  third 
relapse  at  some  time  or  another.  The  death-rate  is  9%  of  the 
average  insane  population  (or  90  per  1000  as  compared  with 
14  per  1000  in  the  general  population). 

The  conclusion  to  be  drai^Ti  from  the  foregoing  figures  is, 


INSANITY,   ITS   INCIDENCE   AND   HISTORY 


that  there  is  an  increasing  number  of  certified  insane  persons 
out  of  proportion  to  the  general  population,  but  that  this 
increase  is  almost  entirely  confined  to  the  pauper  class,  and 
is  largely  due  to  increased  registration  of  insanity,  and  to 
accumulation  of  insane  persons.  The  Lunacy  Commissioners 
who   are    best    qualified  to  form  an   opinion   state    "  that  if 


DISCHARGED  RECOVERED 


DEATHS 


J L 


2-1-,000 


-  l^.OOO 

2,000 
0,000 

_  8,000 
_  6,000 

-  4-,000 
_  2,000 


—  oi  CO  't* 
0000 
0)       C»       O)      0> 


in  CO  (s 
000 
O)     Ot     o 


00      C71      o        — 

O)    at     o>     o> 


Fig.  2. — Chart  showing  the  excess  of  admissions  over  discharges  and  deaths  of 
the  certified  insane  in  England  and  Wales,  from  1901  to  lyll. 

insanity  is  increasing  at  all,  it  is  doing  so  very  slowly,  and  by 
no  means  proportionatel}'  to  the  increasing  numbers  of  insane 
persons  under  care."     (Report  LXV.) 

Historical  Data. — Taking  a  cursor}^  glance  at  the  past, 
it  would  appear  that  so  far  as  histor}'  goes  there  never  was  a 
time  in  which  insanity  was  not  recognised  in  some  form  or 
other,  although  the  frequenc}^  of  its  incidence  can  only  be 


6  MENTAL   DISEASES 

conjectured.  In  primitive  times  it  was  invariabty  attributed, 
as  coming  from  the  gods,  and  its  treatment  confided  to  the 
priests.  For  the  most  part,  insanity  was  regarded  as  due  to 
evil  spirits  and  demoniacal  possession  which  required  exorcism  ; 
but  in  other  cases  it  was  ascribed  to  divine  inspiration,  com- 
manding respect  and  even  worship,  the  latter  being  still  evident 
in  Mohammedan  countries. 

In  Egypt  more  than  5000  years  ago,  mental  troubles  are 
mentioned  on  papyri,  and  temples  existed  for  the  purification 
of  the  insane.  Alcoholic  intemperance  occurred,  and  certain 
persons  were  advised  to  be  abstainers.  When  in  later  times 
Alexandria  was  at  its  zenith,  what  records  remain  show  that 
a  fairly  accurate  knowledge  of  insanity  existed  then.  In  the 
Bible,  madness  is  referred  to  amongst  the  Hebrews.  Saul 
suffered  from  fits  of  jealousy  and  melancholy,  and  Nebuchad- 
nezzar for  years  was  deluded,  believing  himself  to  have  been 
transformed  into  an  animal,  whilst  David's  behaviour  before 
the  King  of  Gath  is  a  conspicuous  example  of  feigned  insanity. 

Mental  disorder  is  also  mentioned  by  Greek  writers :  for 
example  the  story  of  Hercules  committing  homicidal  acts  in 
epileptic  fury,  and  the  feigned  insanity  of  Ulysses  when  he 
was  compelled  to  join  the  army  against  Troy. 

To  Hippocrates  the  Father  of  Medicine,  who  lived  500  B.C., 
must  be  ascribed  the  honour  of  being  the  first  to  establish 
insanity  and  epilepsy  as  natural  diseases  due  to  disorders  of 
the  brain,  and  requiring  the  skill  of  physicians  rather  than 
that  of  priests.  He  also  recognised  the  effect  of  bile,  and  his 
divisions  of  insanity  are  still  the  fomidation  of  most  modern 
classifications.  Plato,  in  his  Republic,  made  provision  for 
the  insane,  and  Aristotle  had  some  knowledge  of  the  nature 
of  hallucinations,  but  he  appeared  to  neglect  the  brain,  and 
to  place  mental  affections  in  the  region  of  the  heart. 

Amongst  the  Romans,  we  read  of  insane  characters  in  Horace, 
and  other  writers.  It  was  the  Roman  custom  to  throw  their 
infant  weaklings  over  the  Tarpeian  Rock,  and  restraint  and 
flogging  for  mental  disease  were  much  in  evidence,  the  notion 
of  possession  by  evil  spirits  being  still  popularly  held.  It 
must,  however,  be  acknowledged  that  some  of  the  enlightened 
Greek  and  Roman  physicians  disapproved  of  this  notion,  and 
advocated  more  humane  methods  of  treatment. 


INSANITY,   ITS   INCIDENCE  AND  HISTORY        7 

In  the  transitional  period  of  the  Middle  Ages,  the  insane 
were  again  almost  entirely  in  the  hands  of  ecclesiastics,  and 
the  knowledge  spread  by  Hippocrates  lay  dormant.  Mental 
diseases  were  attributed  to  demons.  Dancing  manias  were 
frequent,  and  among  witches  there  were  many  insane  people 
who  were  burnt  at  the  stake. 

When  we  come  to  the  Renaissance,  we  are  indebted  to 
Shakespeare  for  his  masterly  delineations  of  characters  illus- 
trating insanity — e.  g.  KLing  Lear,  Ophelia,  Lady  Macbeth  and 
Hamlet,  whilst  the  congenital  fool  {e.g.  Cahban)is  conspicuous 
in  some  of  his  plays.  The  character  of  Hamlet  is  particularly 
interesting,  as  it  is  usually  regarded  as  a  good  example  of 
feigned  insanity.  In  the  seventeenth  century  the  physician  and 
anatomist,  Thomas  WiUis,  revived  the  doctrine  of  the  relation 
of  mind  and  brain,  that  had  been  recognised  onty  by  a  minority 
of  the  sages  of  the  past.  At  the  begiiming  of  the  nineteenth 
century  Gall  and  Spurzheim  founded  their  phrenological  school, 
which  held  sway  mitil  the  present  scientific  era  of  cortical 
localisation  was  established. 

From  the  ecclesiastics  in  the  dark  ages,  the  care  of  the 
insane  passed  gradually  into  the  hands  of  \&j  speculators. 
There  were  but  very  few  asylums  in  existence,  and  the  old- 
fashioned  madhouses  came  into  vogue  to  supplement  them,  a 
great  number  of  the  pauper  insane  being  housed  in  prisons. 
Many  of  these  houses  were  grossly  mismanaged,  and  there  was 
no  legal  visitation  or  protection  for  the  insane  except  for  those 
possessing  propert}^,  the  latter  being  in  the  hands  of  lawyers 
and  the  Court  of  Chancery.  Even  at  the  beginning  of  the 
nineteenth  century  the  condition  of  the  insane  was  pitiable 
in  the  extreme.  The  mental  breakdown  of  George  III  did  more 
than  anything  else  to  rouse  public  attention  to  the  existing 
plight  of  the  insane.  The  poorer  classes  especially  were 
disgracefully  housed,  roughly  used,  poorly  clad,  and  had  to 
sleep  on  straw  beds,  in  dark  ill- ventilated  cells,  with  no  facihties 
for  cleanliness.  Fear  was  inculcated  into  those  that  resisted, 
by  a  system  of  violence  on  the  part  of  the  "  keepers."  Chains 
and  manacles  were  the  rule  rather  than  the  exception,  stripes 
were  ordered,  and  revolving  chairs  were  resorted  to.  The 
head  was  shaved  and  blistered,  and  patients  were  plunged 
suddenly  into  '"surprise"    cold   baths.     On   the    supposition 


8  MENTAL   DISEASES 

that  patients  needed  "  lowering  "  treatment,  they  were 
underfed,  Antimony  was  prescribed  in  heroic  doses,  emetics 
were  administered,  and  copious  purging  and  bleeding  were 
resorted  to.  The  only  sedative  Imown  was  Opium,  and 
patients  were  occasionally  narcotised  to  death.  The  relics 
of  the  instruments  of  barbarism  used  in  olden  days  are  to 
be  seen  in  the  museums  of  Bethlem  Hospital  and  other  old 
asylums. 

There  exist  at  least  three  different  illustrations  of  the  un- 
fortunate man  William  Norris,  who  for  nine  years  was  confined 
in  chains,  and  could  only  move  a  distance  of  twelve  inches. 
The  one  here  depicted  (Fig.  3)  is  taken  from  a  sketch  from 
life  by  G.  Arnald,  A.R.A.,  which  was  exhibited  in  evidence 
before  the  House  of  Commons  by  a  private  Committee  in 
1815.  It  was  etched  by  George  Cruikshank  and  printed  for 
William  Hone,  who  served  on  that  Committee.  A  reproduction 
appears  in  William  Hone  :  His  Life  and  Times,  by  F.  W.  Hack- 
wood,  recently  published  by  T.  Fisher  Unwin,  in  which  volume 
is  to  be  found  a  full  account  of  this  poor  maniac,  as  well 
as  in  the  Story  of  Bethleheyn  Hospital,  by  the  Rev.  E.  G. 
O'Donoghue,  the  present  Chaplain  of  that  institution. 

Bethlem  Hospital,  now  a  model  of  efficiency  and  widely 
renowned,  has,  during  the  process  of  ages,  undergone  profound 
changes.  It  was  originally  founded  as  a  Priory  by  the  Bishop 
of  Bethlehem  in  1247,  on  the  site  of  Liverpool  Street  and  the 
G.  E.  R.  station.  It  was  seized  by  Edward  III  in  1375,  and  a 
year  or  so  later  the  patients  of  a  mediaeval  asylum  in  "  Trafalgar 
Square  "  were  transferred  to  the  care  of  the  Bishopsgate  hospice. 
Henry  VIII  granted  a  charter  in  1546-7,  handing  over  the 
building  to  the  City  of  London,  for  the  use  of  the  insane,  and 
eleven  years  later  it  was  transferred  to  the  Governors  of  Bride- 
well. This  was  the  first  Bedlam  as  mentioned  in  the  plays  of 
Shakespeare,  but  as  early  as  1377  there  is  record  of  insane 
patients  residing  there.  In  1619  the  first  regular  medical  officer 
was  appointed,  and  it  soon  became  manifest  that  the  Hospital 
was  not  large  enough  and  was  unfit  for  its  work.  Therefore,  in 
1675,  the  second  Bethlem,  as  known  to  Hogarth,  was  built  at 
Moorfields.  It  accommodated  120  patients,  and  was  more  or 
less  of  a  public  show-place.  This  was  superseded  by  the  third 
and  present  Bethlem  opened  at  Lambeth  in   1815,  to  which 


INSANITY,    ITS   INCIDENCE   AND   HISTORY        9 


Fig.  3. —  The  old  system  of  treatnient. 


10  MENTAL   DISEASES 

additions  have  been  made,  especially  between  1838  and  1852, 
resulting  in  the  present  stately  edifice.  It  is  pre-eminently  the 
registered  hospital  for  acute  mental  disorders  in  the  educated 
middle  classes,  and  with  its  splendid  revenue  it  is  able  to  do 
valuable  philanthropic  work ;  it  is  also  an  important  centre 
for  teaching  purposes.  Since  1871  it  has  had  a  branch  conva- 
lescent establishment  at  Witley. . 

The  abolition  of  mechanical  restraint  in  the  treatment  of 
insanity,  which  marks  the  present  humanitarian  epoch,  is  one 
of  the  most  brilliant  achievements  in  the  annals  of  Medicine.  It 
began  with  Pinel  at  the  Bicetre  Asylum  in  Paris  at  the  time  of  the 
French  Revolution,  and  simultaneously  in  England  with  William 
Tuke,  who  founded  the  York  Retreat  in  1792,  and  was  followed 
by  the  strenuous  efforts  of  Esquirol  in  France,  of  Rush  in 
America,  and  of  Conolly  and  Gardiner  Hill  in  England,  the 
former  at  Hanwell,  and  the  latter  at  Lincoln,  so  that  when 
Queen  Victoria  ascended  the  throne  a  new  era  for  the 'insane 
had  arisen.  The  events  described  by  Charles  Reade  in  Hard 
Cash,  and  the  story  of  Valentine  Vox  by  Henry  Cockton, 
although  prejudiced  and  greatly  exaggerated,  no  doubt  had 
some  effect  on  public  opinion.  In  recent  times  with  the  wider 
circulation  of  newspapers,  there  has  been  no  demand  for  such 
sensational  literature,  although  an  American  production,  The 
Mind  that  Found  Itself,  by  Clifford  W.  Beers,  is  to  be  noted. 

Looking  at  the  evolution  of  legislation  affecting  the  insane, 
it  must  be  pointed  out  that  it  was  not  until  1828  that  it  was 
enacted  that  patients  of  the  private  class  sent  to  asylums 
should  have  the  attestation  of  two  medical  men.  Before  that, 
only  one  was  required,  and  in  the  previous  century,  none  at 
all.     Pauper  patients  were  treated  merely  as  prisoners. 

As  a  result  of  the  report  of  a  Parliamentary  Committee  in 
1844,  Lord  Shaftesbury  brought  in  a  bill  establishing  the 
Board  of  Lmiacy  Commissioners,  with  the  duty  of  inspecting 
regularly  all  asylums  in  England  and  Wales.  Previous  to 
this,  the  Royal  College  of  Physicians  had  been  entrusted  with 
the  nomination  of  certain  physicians  to  visit  the  asylums  in 
the  Metropolitan  District.  The  management  of  the  registered 
hospitals  and  better  class  asylums  for  private  patients  had 
greatly  improved,  but  there  was  no  adequate  accommodation 
for  the  pauper  insane.     In  1808  powers  were  granted  to  the 


INSANITY,   ITS  INCIDENCE  AND   HISTORY      11 

local  Justices  to  build  asylums  out  of  the  local  rates,  but  this 
was  not  made  compulsory  till  1845. 

In  1890  the  duties  of  asylum  administration  were  transferred 
from  the  Justices  to  the  newly  elected  County  Councils,  to  whom 
chiefly  belongs  the  credit  of  erecting  the  new  palatial  buildings 
for  the  insane  poor.  The  plight  of  the  idiot,  the  imbecile,  and 
the  congenital  feeble-minded,  although  long  recognised,  was 
slow  to  receive  attention;  it  was  not  until  1846  that  an  idiot 
asylum  or  training  establishment  was  built  for  them  in  England. 
Even  at  the  present  time  the  accommodation  for  these  defec- 
tives is  very  insufficient.  Li  1890,  with  the  introduction  of 
the  new  Lunacy  Act,  the  admission  orders  for  private  patients 
to  asylums  by  the  relatives  were  supplemented  by  those  of 
magistrates.  This  further  judicial  incursion  into  the  domain 
of  Medicine  has,  on  the  whole,  proved  beneficial  in  allaying 
public  suspicion,  although  it  arose  largely  from  false  charges 
in  connexion  with  the  detention  of  alleged  sane  persons,  noije 
of  which  could  be  substantiated  before  the  Parliamentary 
Committee  of  1877. 

The  latest  legislation  embraces  provision  for  the  Mentally 
Deficient,  who  do  not  come  within  the  scope  of  the  Lunacy 
Act,  and  who  at  present  are  at  large  to  the  detriment  both  of 
themselves  and  of  society.  It  is  noticeable  also  that  the 
Central  Authority  for  Lunacy,  which  hitherto  has  been  vested 
in  the  Lord  Chancellor,  is  gradually  being  transferred  to  the 
Home  Secretary,  in  company  with  other  medical  departments. 

The  illustration  overleaf  (Fig.  4)  is  taken  from  one  of  the 
modern  asylums  of  to-day,  where  open-air  treatment  and 
female  nursing  for  acute  cases  are  much  in  vogue.  It  exhibits 
a  marvellous  change  that  has  taken  place  within  the  memory 
of  many  psychiatrists. 

The  general  orderliness  and  quietude  of  the  majority  of 
patients  in  the  asylums  of  to-day  are  features  to  be  proud 
of,  in  comparison  with  the  past.  Greater  liberty  is  allowed 
to  patients.  The  nurses  are  properly  trained,  and  a  humani- 
tarian hospital  system  has  been  instituted.  Mental  pathology, 
linked  as  it  is  at  last  mth  general  Medicine,  cannot  fail  to 
open  up  a  fresh  vista  from  which  much  progress  will  result 
in  the  more  scientific  treatment  of  insanity.  The  mystic  veil 
that  has  too  long  shrouded  its  study  has  been  lifted ;  scientific 


12 


MENTAL   DISEASES 


methods  are  penetrating  into  mental  problems,  and  are  replacing 
the  abstruse  speculations  of  the  past.  Psychological  labora- 
tories are  being  established,  and  the  best  asylums  are  becoming 
equipped  with,  pathological  departments  in  which  enthusiastic 
workers  are  searching  for  truth.     Diplomas  in  Ps^^chological 


Fig.  4. — A  modern  method  of  treatment. 

Medicine  have  been  instituted,  the  general  hospitals  have  their 
mental  out-patient  cliniques,  and  the  public  are  alive  to  the 
important  issues  underlying  the  facts  of  heredity,  and  their 
bearing  on  the  race.  The  general  causation  of  insanity,  and 
its  prevention,  are  widely  discussed.  Insanity  is  now  generally 
recognised  by  the  lait}'  as  disease  of  the  brain,  and  the  mystery" 
attaching  to  it  has  in  great  measure  disappeared. 


CHAPTER   II 
MIND,    CONSCIOUSNESS,    SLEEP,    MEMORY 

Psychology  in  relation  to  Insanit}^  will  form  the  basis  of 
this  and  of  the  three  succeeding  chapters.  It  is  intended  to 
give  an  outline  of  normal  mental  processes,  and  to  describe  the 
disorders  they  are  liable  to  in  the  symptomatology  of  Insanity. 
The  physical  substrata  underlying  these  mental  processes  will 
also  receive  special  attention  from  the  neurological  point  of 
view. 

The  subject  of  Mental  Diseases  or  Insanity,  or  what  is  some- 
times called  Psychological  Medicine  or  Psychiatry,  is  daily 
becoming  more  important  to  the  student  and  practitioner. 
For  the  clearer  understanding  of  the  sjTnptoms  of  the  mind 
diseased,  it  is  felt  that  some  brief  reference  should  first  be  made 
to  mental  processes  in  a  state  of  health.  This  is  rendered 
necessary,  since  in  their  preliminar}^  studies  most  medical 
students  have  paid  but  scant  attention  to  psj^chology  in  the 
academic  sense.  This  is  mostkly  due  to  the  inherent  difficulty  of 
the  subject,  and  to  some  extent  also  to  the  amount  of  obscure 
terminology  that  is  brought  into  pla3^  Authors  are  naturally 
apt  to  look  at  the  problems  of  mind  from  their  o^vn  special 
standpoint.  The  philosopher,  the  theologian,  the  lawyer,  and 
the  physician,  each  tinges  the  same  subject-matter  with  his 
own  particular  aspect,  and  any  attempt  to  correlate  these 
views  often  leads  the  student  into  a  maze  of  confusion.  He  is 
therefore  apt  to  leave  the  subject,  which  he  concludes  is  com- 
posed of  idle  words,  devoid  of  meaning  and  without  interest 
or  practical  utility.  The  medical  student,  trained  as  he  is  to 
habits  of  observation  and  experiment,  finds  himself  confronted 
mth  problems  in  which  something  more  is  now  required  of 
him  when  he  begins  the  study  of  Ps^^chological  Medicine .  The 
methods  of  objective  study  which  he  has  developed  so  far  are 

13 


14  MENTAL   DISEASES 

sufficient  for  a  xight  understanding  of  the  physiology  of  the 
senses.  He  has  now,  however,  to  bridge  a  chasm  for  the  appre- 
hension of  the  physiology  of  mind  or  those  mental  operations, 
in  which  not  only  are  these  methods  necessary  so  far  as  they 
can  be  applied,  but  also  the  study  of  the  subjective  mechanism 
of  his  own  mind  must  take  part. 

Mind  is  the  power  a  person  possesses  of  Thinking,  Feeling, 
Desiring,  and  Willing,  with  the  accompanying  processes  of 
Memory  and  Attention,  by  which  means  also  a  person  becomes 
aware  of  his  surroundings  and  their  relation  to  Space  and  Time . 

These  cognitive,  affective,  and  conative  functions,  as  they 
are  sometimes  called,  we  shall  find,  as  in  other  departments 
of  Medicine,  are  associated  with  a  person's  organisation  or 
structure,  which  is  derived  from  his  parentage  and  from  his 
experience,  training,  and  education. 

Psychology  does  not,  however,  confine  itself  to  the  study  of 
mental  states  only,  but  is  regarded  as  having  a  wider  applica- 
tion by  McDougall  and  other  authorities.  It  concerns  itself 
with  the  conduct  (or  behaviour)  of  animal  life  in  general,  using 
the  word  conduct  as  the  sum  of  purposive  activities  by  which 
an  animal  adapts  itself  to  its  surroundings.  The  sister  or  sub- 
science  of  Ethics  treats  of  right  conduct,  that  is,  conduct  as  it 
ought  to  be,  or  the  special  study  of  the  moral  and  other 
sentiments. 

Objective  or  Physiological  Psychology  is  that  branch  of  the 
subject  which  treats  mostly  of  experimental  methods,  and  which 
is  best  adapted  to  the  special  senses  subserving  our  mental 
life. 

Subjective  'Psychology  necessitates  self-analysis  or  intro- 
spection and  retrospection  into  our  present  and  past  mental 
states  ;  what  really  takes  place  in  the  minds  of  others  is  only  an 
inference  by  the  inquirer,  and  is  arrived  at  by  conjecture,  and 
requires  confirmation  by  objective  methods  so  far  as  they  are 
possible. 

What  the  essence  of  Mind  is,  resolves  itself  into  a  pure 
speculation.  What  is  matter — never  mind  :  what  is  mind- — 
no  matter,  is  an  old  axiom  of  the  dualist  school.  Dualism 
means  either  parallelism  or  interactionism.  In  the  former  there 
is  regarded  concomitance  between  psychical  and  physical 
processes  with  no  connexion  between  them,  whereas  in   the 


MIND,   CONSCaOUSNESS,   SLEEP,   MEMORY       15 

latter,  interaction  is  siipj)osecl  to  exist  between  the  mental  or 
spiritual  world  and  material  or  nervous  processes. 

Both  matter  and  mind  can  be  considered  as  manifestations 
of  force  or  energy  in  Nature  from  the  monist  point  of  view,  and 
the  materialistic  or  s^^V^^w«Z^5^^c  hypotheses  as  to  body  and  mind 
may  be  two  aspects  of  the  same  thing.  A  useful  analogy  of  the 
relationship  of  pyschical  to  physical  processes  is  that  of  the 
production  of  magnetic  force  by  electrical  currents.  Although, 
strictly  speaking,  mental  and  material  phenomena  should  not  be 
spoken  of  in  the  same  terms,  it  is  however  helpful  to  the  student, 
so  far  as  is  possible,  to  have  psychological  states  and  their 


Dualism  Monism 

m    CoHClOUSNESS 

Fig.  5. — Dualism  and  Monism. 

neuronic  bases  described  side  by  side,  and  an  occasional 
admixture  of  terms  is  almost  excusable  for  want  of  precise 
terminology. 

Without  entering  into  the  question  of  sensibility  in  the  vege- 
table kingdom  or  even  in  inanimate  matter,  allied  to  that  pro- 
ducing sensation  in  the  animal  kingdom,  the  query  is  whether 
mental  and  other  phenomena  of  life  can  be  explained  on 
mechanical  principles  only,  or  whether  there  exists  some  vital 
essence  or  soul,  as  the  Animists  assert.  The  student  may,  in 
either  case,  regard  the  dawai  of  mind  best  from  the  Evolutionary 
standpoint.  He  then  finds  what  may  be  inferred  to  be  mental 
phenomena  arising  when  an  animal  by  means  of  its  specialisa- 
tion possesses  a  nervous  system,  involving  reflex  arcs  by  which 
it  adapts  itself  to  its  environment,  and  the  higher  the  complexity 


16  MENTAL   DISEAvSES 

of  that  nervous  S3^stem,  the  more  sureh'  do,  what  we  call,  mental 
phenomena  present  themselves.  It  is,  however,  Avhen,  in  the 
scheme  of  creation  nervous  gangha'  conglomerate  into  what  we 
call  a  Brain,  that  we  are  still  more  certain  in  our  conviction  that 
there  exists  what  may  be  called  Mind.  As  w^e  study  the  ascent 
of  the  animal  kingdom  so  do  we  find  the  gradual  development 
of  Mind  pari  passu  with  the  evolution  of  the  Brain.  Yet  even 
this  self-evident  fact  is  comparatively  new  to  the  knowledge  of 
the  majority  of  the  human  race.  The  ancients  for  the  most 
part,  with  the  exception  of  Hippocrates  and  Galen,  considered 
the  Mind  as  something  not  onh"  independent  of  the  body,  but 
they  possessed  very  hazj^  notions  of  its  connexion  therewith. 
They  imagined  the  Mind  to  reside  perhaps  in  the  heart  or 
abdomen,  and  the}"  regarded  the  brain  merely  as  a  gland  to 
cool  the  blood,  which  supposition  received  the  support  of  so^ 
eminent  a  philosopher  as  Aristotle.  That  the  Brain  is  the 
organ  of  mind  now  appears  as  a  truism  scarcely  worth}"  of  men- 
tion, as  does  the  fact  that  the  part  of  the  brain  that  subserves 
psychical  functions  is  the  Cortex  of  the  Cerebral  Convolutions. 
Here  also  reside  the  supreme  trophic  centres  for  the  nutrition 
of  the  body,  the  Cerebellum  being  regarded  as  a  co-ordinating 
organ  mth  the  labyrinth  for  the  muscular  mechanism  and 
having  afferent  and  efferent  connexions  with  the  Cortex,  the 
lower  brain  being  composed  of  centres  for  the  affective  organic 
and  vital  processes,  and  containing  stations  and  paths  of 
conduction  to  and  from  the  Cortex  and  the  other  parts  of  the 
nervous  system. 

Consciousness  is  fundamentally  inexplicable.  It  is  com- 
posed of  a  unity  of  ideas,  feelings,  volitions,  etc.,  and  is  the 
term  used  when  mental  functions  are  in  their  fullest  vigour. 

In  its  subjective  sense — Subject  consciousness — the  pos- 
sessor becomes  aware  of  his  Ego — or  that  particular  mental 
state  that  occurs  at  the  moment,  which  is  sjaithetically  made 
up  of  the  sum  of  impressions  from  within  and  from  without 
then  prevailing.  These  embrace  sensations,  perceptions, 
ideas,  feelings,  desires,  and  volitions,  together  with  the  mem- 
ories of  past  experience.  The  Self,  Personality,  or  Identity 
of  an  individual  is  the  result  of  the  memories  of  the  "  Ego  " 
at  different  times,  and  is  dependent  on  the  specific  essence 
or  nature  of  the  mental  constitution,  or,  in  other  words,  on 


MIND,   CONSCIOUSNESS,   SLEEP,  MEMORY       17 

the  quality  and  elaboration  of  the  cortical  nerve  elements.  It 
must  also  be  supposed  to  include  to  some  extent  the  corporeal 
nature  of  the  person  in  question,  for  when  a  person  speaks 
of  himself  he  means  his  body,  soul,  and  spirit ;  interpreting 
the  word  "spirit"  as  what  we  usually  call  "mind,"  the 
word  "soul  "  as  a  unifying  principle  in  its  psychological  and 
religious  significations,  and  the  word  body  in  its  material 
sense.  By  the  term  Self -consciousness  is  meant  that  an  indi- 
vidual is  given  to  introspection,  and  any  undue  intensity  in 
this  direction  is  accompanied  by  abstraction,  and  a  neglect 
in  the  influences  of  the  environment,  which  occurs  particularly 
in  states  of  depression  and  day  dreaming.  In  its  objective 
sense  Object  consciousness — the  mind  develops  its  tendencies 
in  discriminating  its  perceptions  of  the  external  world. 


Subconsciousness. 

/  i  t\\  \ 

I       d       3         — E 1 1 Consciousness. 

V  \  V//  j 

Unconsciousness 

Fig.  6. — Graphic  representation  of  mind. 

Consciousness  exists  in  all  degrees ;  its  stream  may  be  said 
to  flow  in  different  directions,  so  that  a  fringe  of  consciousness 
is  sometimes  spoken  of,  below  the  margin,  limen,  or  threshold 
of  which  is  postulated  Subconsciousness,  in  which  mental 
functions  of  a  dim  kind  occur  fading  into  the  realm  of  Uncon- 
sciousness (Fig.  6).  Here  the  mind  may  be  said  to  be  in  abey- 
ance, yet  the  mechanism  is  such  that  the  springs  of  mental 
action  exist  in  the  lower  nervous  connexions  in  which  there 
is  no  breach  of  continuity  from  the  lower  to  the  higher.  Sub- 
conscious mental  activities  have  in  recent  times  attracted 
much  attention,  especially  in  the  investigation  of  Dreams, 
Hysteria  and  other  allied  conditions,  in  which  probably  the 
subconscious  elements  of  mind  are  the  principal  seat  of 
disorder.  It  may,  indeed,  be  postulated  that  there  is  a 
constant  flux  of  subconscious  sensations,  ideas  and  feelings 

c 


18  MENTAL  DISEASES 

to  the  field  of  consciousness  and  vice  versa  in  every  day  life,  and 
that  subconscious  manifestations  reveal  the  essential  mental 
constitution  of  the  person. 

Disorders  of  Consciousness.  —  Stupor  and  Coma, 
whether  due  to  toxins  from  within,  or  artificially  induced  by 
drugs  or  anaesthetics  such  as  Chloroform  or  Ether,  consist  of 
different  degrees  of  loss  or  clouding  of  consciousness,  with  a 
distinction  peculiar  to  each,  dependent  on  more  or  less  complete 
dissociation.  Dissociation  may  also  lead  to  a  division  of  the 
unity  of  consciousness  into  two  or  more  states.  Thus  arise  cases 
of  Double-  or  Split-consciousness,  the  one  personality  conversing 
with  the  other  personality,  which  not  infrequently  happens 
in  Insanity  and  Delirium,  or  the  normal  state  may  alternate 
with  a  delusional  state  with  entirely  different  memories,  as 
in  Somnambulism  or  Trance,  and  in  some  cases  of  Epilepsy 
and  Hysteria.  Disorder  of  the  subconscious  mental  life  of 
the  individual  exists  in  insanity  and  allied  conditions,  as  well 
as  disturbance  of  full  consciousness,  and  it  has  been  much 
investigated  by  psychologists  of  the  Freud  school. 

Sleep  is  the  natural  state  of  unconsciousness  which  habitu- 
ally occurs  during  about  eight  out  of  each  twenty-four  hours 
in  the  adult  human  subject.  It  is  a  conspicuous  example 
of  the  rhythm  which  pervades  Nature.  During  this  period  of 
rest  or  comparative  functional  inactivity  the  acid  neural 
products  of  fatigue  are  removed,  the  store  of  intra-molecular 
oxygen  is  replenished  so  that  tone  is  restored,  and  conscious- 
ness returns.  Unconsciousness  is  usually  deepest  about  one 
hour  after  falling  asleep,  the  curve  rising  steeply  during  the  first 
hour,  declining  until  the  third  hour,  and  diminishing  there- 
after by  only  a  slight  gradation  till  the  person  awakes  (Fig  7). 

The  curve  of  intensity  of  sleep  varies,  however  in  some 
individuals,  and  is  dependent  on  climatic  and  other  sur- 
rounding conditions.  Some  cases  show  a  slight  second  curve, 
especially  in  children,  in  whom  normal  sleep  is  naturally  more 
prolonged.  In  others  the  primary  curve  may  not  reach  its 
acme  till  the  third  hour,  and  this  is  stated  to  occur  in  persons 
whose  maximum  of  mental  efficiency  is  reached  later  in  the 
day  rather  than  in  the  morning.  During  sleep  the  vital 
processes  are  reduced,  heat  production  is  lessened  and  the 
muscles  are  relaxed.     The  heart  and  respiration  are  slowed. 


MIND,   CONSCIOUSNESS,   SLEEP,   MEMORY        19 

The  blood  pressure  is  reduced.  Both  the  splanchnic  and 
cutaneous  vascular  areas  are  dilated  and  the  skin  is  apt  to 
perspire.  The  intra-cranial  blood-flow  is  diminished  and  the 
cortex  of  the  brain  is  anaemic.  The  pupils  are  contracted 
and  the  eyeballs  tend  to  roU  upwards. 

Various  theories  have  been  formulated  to  explain  the  physical 
basis  of  sleep.  The  more  or  less  rapid  transition  from  conscious- 
ness to  unconsciousness  would  appear  to  be  due  to  cortical 


HOURS        >a        1         1^       2       2%      3        3>i     4       4>.      .        ...       u       c-^      /        />.      « 

Fig.  7.— Curve  illustrating  intensity  or  quaHty  of  sleep   as  shown  by  strength 

KohlsT"         (a  faUmg   ball)    necessary  to  waken    a   sleeping    person    ('after 

vasomotor  influence  of  which  but  little  is  known.  Lugaro  specu- 
lates on  hypothetical  grounds  that  the  gemmules  on  the  dendrons 
protrude  during  sleep,  others  suggest  that  they  contract  and 
cause  dissociation.  It  may  be  that  the  products  of  fatigue 
affect  the  cortical  neurons  to  such  an  extent  that  the  nervous 
potential  is  at  a  very  low  ebb,  and  that  their  sjTiapses  require 
recuperation  for  the  transmission  of  impulses,  the  blocd-vessels 
aiding  secondarily  in  the  process.  In  any  case  it  should  be 
noted  that  auto-suggestibility  of  sleep  and  outside  influences 
also  play  a  part. 


20  MENTAL   DISEASES 

Dreams  occur  niostW  in  light  sleep,  or  in  the  last  or  hypna- 
gogic stage  of  sleep,  not  infrequently  in  the  few  moments 
before  waking  up.  Dreams  exhibit  the  subconscious  life  of 
a  person  deprived  of  any  volitional  control,  and  they  reveal 
past  experiences  in  .a  disorderly  and  grotesque  manner.  They 
have  also  but  little  relation  to  Time,  so  that  incidents  travers- 
ing long  periods  are  distorted  and  revived  during  a  few  seconds, 
and  when  painful  emotion  exists  a  nightmare  results.  The 
interpretation  of  dreams  has  recently  been  the  subject  of  much 
attention  by  Freud  and  other  psychologists,  who  sometimes 
consider  them  as  distorted  or  imaginary  wish-fulfilments  that 
escape  the  censorship  of  the  Will.  From  the  physical  stand- 
point dreams  ma}"  be  regarded  as  due  to  dissociated  islets  of 
the  cortex  being  in  a  state  of  comparative  activit3^ 

Disorders  of  Sleep. — The  quantity  and  quality  of  sleep 
which  are  natural  to  a  person  vary  with  age  and  with 
idiosyncrasy.  Sleeplessness,  or  disordered  sleep  accompanied 
by  excessive  dreaming,  may  arise  from  reflex  disturbances 
from  within  or  from  without,  or  it  may  herald  an  attack  of 
insanity.  Amongst  the  causes  must  be  included  emotional 
disturbances,  bodily  diseases,  and  toxic  agents.  In  neurotic 
children  the  sensorimotor  centres  are  prone  to  become  active 
so  that  they  talk  in  their  sleep,  and  are  occasional^  given  to 
sleep-walking  and  to  night  terrors. 

Insomnia  ma}^  be  regarded  both  as  a  sjTnptom  and  as  a 
cause  of  insanity.  It  is  a  feature  of  Acute  Mania,  Acute  Melan- 
cholia, and  Delirium,  whilst  it  is  usually  present  in  Confusional 
Insanity  and  Alcoholic  Psychoses.  Sleep  is  generalty  excessive 
in  Amentia,  and  also  in  Dementia,  especially  when  accompanied 
by  Organic  Brain  Disease,  and  in  Senile,  Epileptic  and  other 
conditions  such  as  Narcolepsy.  Bad  dreams  are  frequently  a 
warning  of  a  relapse  in  recurrent  insanity. 

Insufficiency  of  sleep  has  a  pernicious  effect  on  the  nutri- 
tional processes  of  the  body  and  when  prolonged  ma}^  lead  to  a 
fatal  issue.  To  the  psychiatrist  a  sleep  chart,  showing  the 
amount  of  sleep  in  an  acute  case,  is  as  important  as  is  a 
temperature  chart  in  ordinary  diseases  (Fig  8). 

Hypnosis  is  a  special  form  of  artificial  sleep  induced  in 
certain  people  whilst  under  the  influence  of  another  person. 
In  this  condition,  suggestions  from  the  hj^pnotiser  are  rein- 


MIND,    CONSCIOUSNESS,   SLEEP,  MEMORY        21 

forced,  and  are  therefore  likely  to  be  carried  into  effect,  and  this 
is  so  especially  in  the  secondary  Somnamb^^Iistic  stage  that  can 
generally  also  be  induced. 

Only  a  certain  type  of  individual  can  be  hypnotised,  and  as 
his  complete  attention  and  co-operation  in  the  process  are 
requisite  it  can  scarcely  ever  be  applied  in  insanity  with  success. 

In  order  to  hypnotise  a  patient  several  trials  may  be  neces- 
sary.    He  should  be  placed  in  a  passive  state,  free  from  external 


Name 

May/9/3. 

DiSEAS 

E. 

Chronic  /Vdn/a 

Date. 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

50 

31 

1 

^      2 

z: 

a     3 

uj      4 

_i 

u. 
O      6 

(Si 

9 

J 

s 

/ 

\ 

/ 

1 

^ 

/ 

\ 

\ 

/ 

\ 

^ 

\ 

/ 

\ 

\ 

/ 

s 

/ 

^ 

/ 

I 

\ 

/ 

\ 

/ 

Notes 

Pulse 

Tehpemw/ie 

Urine 

Bowels 

_. 

Fig.  8. — Chart  showing  daily  amount  of  sleep. 

influences  as  far  as  is  possible  so  as  to  be  dominated  bj"  the 
personality  of  the  hypnotiser,  who  uses  various  means  to  suggest 
sleep.  If  sleep  be  induced,  the  patient  is  then  receptive  to  other 
suggestions  by  the  hypnotiser,  and  it  is  well  to  include  the 
suggestion  that  the  patient  cannot  be  hypnotised  by  anyone 
who  is  not  a  medical  man.  It  should  be  mentioned  that  the 
condition  is  frequently  imitated  by  fraud.  In  some  unstable 
persons  a  transient  hypnoidal  state  short  of  hypnosis  can  some- 
times be  induced  in  which  suggestions  have  moi^e  effect  than 


22 


MENTAL   DISEASES 


in  the  normal  waking  state  ;  this  is  closely  allied  to  the  hypna- 
gogic stage  of  ordinary  sleep.  The  most  probable  explanation  of 
the  ^physical  basis  of  hypnosis  is  that  it  is  due  to  a  slight  degree 


Gemmule; 


Collateral. 


Axon. 


Fig.  9. — The  neuron  (Golgi's  silver  stain  x  60). 

of  dissociation  in  which  there  is  partial  restriction  of  the  func- 
tional activity  of  the  cerebral  neurons. 

The  Physical  Basis  of  Consciousness. — The  neuron 
theory  is  practicall}^  accepted  b}^  neurologists,  and  it  is  probable 
that  the  highest  neurons  of  the  cerebral  convolutions  and  their 


MIND,   CONSCIOUSNESS,   SLEEP,  MEMORY       23 

connecting  media  form  the  physical  substrata  for  Consciousness. 
Partial  destruction  of  the  cortex  cerebri  entails  deficiency  and 
disorder  of  mental  operations,  whilst  a  severe  concussion,  shock, 
or  circulatory  disturbance  suspends  Consciousness  for  a  time, 
and  they  not  infrequently  leave  serious  after-results.  The 
most  probable  hypothesis  is  that  the  essential  cortical  element — 
the  neuron — functions  by  contact  with  others.  The  dendrons 
or  protoplasmic  processes,  as  shown  by  certain  staining 
methods,  have  been  observed  to  have  minute  excrescences  called 
"  gemmules,"  which  according  to  some  authorities  are  thought 

Skin.  Muscle. 


«  \  Motor 
neuron. 


Synapse. 

'bynapse. 

Association  neuron. 
Fig.  10. — Diagram  showing  synapses. 

to  have  amoeboid  powers  of  protrusion  or  retraction  during 
repose  and  activity.  By  others  these  are  regarded  as  arti- 
facts. The  actual  points  of  contact  of  nervous  processes  are 
called  "  synapses,"  which  seem  to  act  as  points  of  resistance 
in  the  transmission  of  impulses.  These  points  of  resistance 
may  be  regarded  hypothetically  as  due  to  impressionable 
cementing  or  receptive  substance.  Each  cerebral  neuron 
or  nerve  cell  has  an  axon  or  axis  cylinder  process  with  its 
branching  collateral  processes  by  which  it  becomes  connected 
by  means  of  synapses  with  the  dendrons  of  other  neurons 
in  a  system  of  terminal  arborisations.  In  the  lower  nervous 
levels  the  synaptic  resistance  is  practically  absent,  the  pro- 
cesses   becoming    continuous    rather    than  contiguous.     The 


24  MENTAL   DISEASES 

body  of  a  neuron  contains  a  nucleus  and  nucleolus  whicli  have 
been  considered  as  having  trophic  properties  for  the  neuron. 
The  matrix  consists  of  fibrils  which  normally  do  not  stain 
(achromatoplasm)  and  are  probably  connecting  links  between 
the  processes.  In  the  matrix  are  certain  granular  bodies — 
Nissl  bodies — which  stain  deeply  with  methylene  blue 
(chromatoplasm)  and  are  possibly  also  of  trophic  function. 
It  has  been  alleged  that  they  do  not  exist  in  the  living  nerve 
cell.  The  rest  of  the  matrix  is  in  direct  continuity  with  the 
different  processes  and  is  concerned  with  the  generation  and 
accumulation  of  nervous  energy  (neurin)  and  the  transmission 
of  nervous  impulses  from  one  neuron  to  another.  These 
impulses  are  the  result  of  receptive  stimuli  which  set  up 
physico-chemical  changes  (katabolism)  producing  a  nerve 
current.  The  transmission  of  a  nerve  impulse,  which  we  learn 
from  physiology  travels  along  a  nerve  fibre  at  the  rate  of  30 
metres  per  second,  overcomes  the  resistance  of  the  synapses  at 
the  points  of  contact  when  as  a  result  of  stimulation  a  neuron 
becomes  overcharged,  and  thus  neurons  are  affected  in 
other  centres,  where  the  energy  is  expended,  or  it  is  finally 
diffused  in  muscular  action. 

The  storage  of  nervous  energy  is  dependent  on  the  anabolic 
functions  of  the  neuron,  by  which  reserve  or  potential  energy 
is  obtained.  This  energy  is  generated  from  the  surrounding 
lymph,  but  it  also  arises  largely  by  transmission  from  the  lower 
levels  of  the  nervous  system,  and  is  derived  for  the  most  part 
from  the  muscular  and  organic  viscera  which  replenish  the 
higher  levels.  In  the  natural  process  of  Senile  decay  the 
cortical  neurons  atrophy,  in  great  measure  from  this  want  of 
vis  a  tergo  especially  from  the  \TLscera. 

Consciousness  being  concerned  with  the  activity  of  the 
highest  neurons  of  the  cortex  cerebri,  fully  charged  with 
energy,  it  may  be  said  to  be  connected  \^dth  the  passage  of 
nervous  impulses  from  neuron  to  neuron  in  the  association  and 
other  areas.  In  these  areas,  organisation,  which  is  the  feature  in 
the  lower  levels  of  the  nervous  s^'stem,  is  onh'  in  process  of  for- 
mation as  mental  growth  proceeds.  It  is  possible  that  the 
action  of  certain  drugs,  and  that  of  the  products  of  fatigue,  may 
affect  the  conductivity  of  the  adjoining  SA^napses  in  these  areas, 
as  much  as,  or  even  more  than,  that  of  the  neurons  themselves. 


Axon. 


Fig.  II. — 'J'lic  normal  nerve  eel!.     (Nissl  x  400.) 

To  lace  puije  24. 


1st  layer. 


4  ',  :•■    '  i 
-4  V..',i  '■ 


2nd  layer. 


3rd  layer. 


4th  layer. 


.3th  layer. 


*    i' 


i   *  ', 


.  ^^ 


;■  V'V.Vv>^ 


^      P  .1.  .         .  .  ■ 


>-  :    ■  .*    -»   \ 
■  •  1 "  -^   •..  . " 

;.  •■    -A  .■  ■:     * 


'i.  ^ 

>    ■  .  ■■." 


♦:    ■   A  i. 

•  ^   ^ .;,  ■' 

>:^M 

.'«,   i     ';' 

--»*.■ 

i  ■  .  '  fc 

;  *  ••?  . 

_^iltL 


Fig.  12. — Strip  of  normal  motor 
cortex,  showing  nerve  fibres. 
(Weigert-Pal  X  45.) 


Fig.  13. — Strip  of  normal  motor 
cortex,  showing  nerve  cells. 
(Nissl  X  45  ) 

[To  face  page  25. 


MIND,    CONSCIOUSNESS,   SLEEP,   MEMORY       25 

On  this  hypothesis.  Consciousness  may  be  regarded,  as  dependent 
on  the  transmission  of  nervous  impulses  through  cortical 
synapses.  This,  moreover,  affords  some  explanation  of  the 
action  of  Str^^chnine  as  diminishing  the  resistance  of  sj^napses 
and  thus  intensifying  Consciousness,  and  of  the  soporific  effects 
of  the  products  of  fatigue,  of  Chloroform,  and  of  hypnotics  or 
sedatives  in  general. 

The  neuron  or  essential  unit  underlying  mental  functions 
having  been  briefly  described,  it  remains  to  consider  the 
Cortex  Cerebri  from  the  psychiatrist's  point  of  view,  and  to 
ascertain  what  specialisation  as  to  structure  and  fmiction  in 
its  various  parts  is  exhibited.  Beyond  the  presence  of  occa- 
sional neuroglial  elements  and  the  blood  and  lymph  channels, 
its  grey  matter  is  composed  of  m3Tiads  of  neurons  with  their 
inter-connecting  processes  or  fibres.  The  neurons  of  a  normal 
individual  are  probably  numericalh^  all  present  at  birth  and 
their  processes  develop  during  mental  growth.  It  has  been 
computed  that  there  are  fully  3000  millions  of  neurons  in 
the  human  brain. 

The  cortex  varies  somewhat  in  thickness  and  composition 
in  different  regions.  Its  minute  anatomy  consists  of  five 
chief  layers  interspersed  by  fibres,  viz.  from  the  surface  inwards, 
(1)  the  superficial  or  molecular  la3^er,  containing  also  outer  nerve 
fibrils;  (2)  the  broad  layer  of  supragranular  pyramidal  cells, 
large  and  small  (outer  cell  layer) ;  (3)  the  layer  of  granules 
(middle  cell  layer) ;  (4)  the  layeT  of  inner  nerve  fibres  (Bail- 
larger 's  laj^er)  with  a  few  solitary  pj^ramidal  cells,  and  with 
the  giant  Betz  cells  in  the  Frontal  lobe ;  (5)  the  layer  of  poty- 
morphous  cells  (inner  cell  layer). 

The  second  layer — the  \a.yer  of  supragranular  pyramidal 
cells  is  most  developed  in  the  Frontal  lobe  and  probably 
subserves  complex  actions  and  ideational  operations.  Ac- 
cording to  J.  S.  Bolton  it  is  the  last  to  be  developed,  and  the 
first  to  degenerate  in  insanit}^,  and  it  is  therefore  an  index  of 
mental  capacit3^ 

The  third  layer — of  granules — is  best  developed  in  the 
sensory  areas,  and  it  is  therefore  probably  afferent,  co-ordi- 
nating impressions  from  the  thalamus  and  from  other  regions 
of  the  cortex. 

The  fifth  layer — of  polj^morphous  cells — may  be  regarded 


26 


MENTAL   DISEASES 


possibl}'  as  subserving  efferent  actions  of  organic  type,  as 
may  perhaps  also  the  infragranular  sohtary  and  Betz  cells  in 
the  fourth  layer. 

The  nerve  fibres  are  both  meduUated  and  non -medulla ted, 
and  connect  with  the  white  matter  by  means  of  vertical  or 
radial  fibres  consisting  mostty  of  direct  axons,  afferent  and 
efferent.  They  naturally  decrease  in  density  as  they  approach 
the  surface  of  the  cortex.  The  tangential  fibres  occupy  two 
main  strata,  those  in  the  first  layer  forming  the  plexus  of 
Exner,  those  in  the  fourth  layer  being  interspersed  with  a 
few  solitary  cells.  They  consist  of  dendrons,  and  of  collaterals 
of  axons  and  their  terminal  arborisations. 


Fig.  14. — The  association  fibres  of  the  cerebrum. 

The  subjacent  white  matter  consists  of  meduUated  fibres 
arranged  in  bmidles  and  separated  by  neuroglia,  and  may  be 
divided  into  three  distinct  sj^stems  :  (1)  The  projection  fibres 
consisting  of  afferent  and  efferent  fibres  which  connect  the 
cortex  with  the  basal  ganglia  and  lower  parts  of  the  nervous 
sj'stem.  (2)  The  transverse  or  commissural  fibres  connecting 
the  two  hemispheres  by  means  of  the  corpus  callosum,  etc. 
(3)  The  association  fibres — short  and  long — connecting  different 
parts  of  the  same  hemisphere  (Fig.  14). 

During  the  past  half  century  the  mapping  out  of  cerebral 
functions  has  arrived  at  a  further  state  of  precision,  and  has 
altogether  superseded  the  old  phrenological  doctrine  of  local- 
ising faculties,  which  was  without  any  foundation  whatever. 


MIND,   CONSCIOUSNESS,   SLEEP,   MEMORY  27 


—  _o 


Motor  dextsriti33 


Ideational. 


^'i■;ual  perception. 
Auditory  psrceptiou. 


Auditory  sensation. 
Fig.  15. — Cerebral  localisation,  external  surface. 


Motor  dexterities. 


Stereognosis 


Visual  perception 


Auditory  perception.         Auditory  sensation. 
Fig.  16. — Cerebral  localisation,  mesial  gwface. 


28  MENTAL   DISEASES 

By  studying  the  myelinisation  of  fibres  and  as  a  result  of 
pathological  and  experimental  investigations  the  cortex  has 
been  divided  into:  (1)  Projection  areas  consisting  of  the 
Rolandic  sensorimotor  centres  and  the  special  sense  centres ; 
and  (2)  Association  areas  which  are  highly  developed  in 
man,  and  occupy  two -thirds  of  the  cortex.  The  latter  are 
more  particularly  the  substrata  for  psychical  processes 
although  the  entire  cortex  probably  operates  in  the  content 
of  Consciousness. 

As  regards  the  projection  areas  the  Rolandic  region  is 
divided  by  its  fissure  into  an  anterior  part  (pre-central)  which 
is  motor  (efferent  projection),  and  a  posterior  part  (post- 
central) which  is  sensory  and  kinsesthetic  (afferent  projection). 
The  special  sense  centres  have  also  been  ascertained  with 
accuracy. 

The  Association  areas  of  Flechsig  have  their  distribution 
in — 

(1)  The  Pre -Frontal  lobe. 

(2)  The  Post-Parietal  lobe. 

(3)  The  Occipito-Temporal  lobe. 

(4)  The  Island  of  Reil. 

The  perception  centres  for  sight  and  hearing  (visual  psychic 
and  auditory  psychic)  radiate  from  their  respective  sensory 
centres  in  the  projection  areas,  and  it  may  fairly  be  surmised 
that  perception  for  the  other  special  senses  radiate  from  their 
sensory  centres  in  a  similar  manner.  The  rest  of  the  associa- 
tion areas  are  concerned  with  ideational  processes,  and  co- 
ordinate the  emotional  tone  derived  from  the  subjacent 
thalamic  neurons ;  the  substrata  for  ideomotor  actions  and 
volitions  are  formed  in  the  Pre -Frontal  lobe,  which  is  the 
latest  in  the  stage  of  evolution,  and  indeed  its  extreme  anterior 
portion  is  rudimentar}^  histologically  and  apparently  function- 
less  (A.  W.  Campbell). 

Memory  is  the  revival  of  past  impressions  and  is  indis- 
pensable for  all  psychical  processes,  whether  conscious  or  not. 
Memory  is  requisite  for  mental  retention,  and  has  therefore  by 
many  authors  been  dignified  into  a  special  faculty  of  the  mind. 
To  speak  of  memory,  therefore,  generally  connotes  the  revival  of 


MIND,   CONSCIOUSNESS,   SLEEP,   MEMORY       29 

past  ideas,  perceptions,  and  experiences.  It  is  variable  in 
different  individuals,  and  is  largely  dependent  on  the  quality 
of  the  mental  fabric  as  well  as  on  its  elaboration.  Memor}^  is 
keenest  in  3'outh  and  diminishes  as  age  advances.  Many  imbe- 
ciles have  remarkable  memories,  especially  for  calculating  figures, 
whilst  the  memory  of  ordinar}'  or  even  clever  men  is  not  infre- 
quentl}'  defective  in  some  respects.  Events  may  be  remem- 
bered better  through  one  special  sense  than  through  another ; 
thus  one  person  has  a  good  visual  memor}'  and  a  bad  auditor}' 
memory,  and  vice  versa.  Of  some  importance  is  the  dis- 
crimination of  matters  requiring  no  committal  to  memory: 
this  involves  the  exercise  of  the  faculty  of  attention.  Many 
means  have  been  devised  to  improve  and  assist  memory, 
the  most  efficacious  of  which  is  the  proper  method  of 
forming  associations.  ^^Tien  recalling  reminiscences  it  is 
frequently  best  to  allow  the  associations  to  proceed  sub- 
consciously, and  then  the  required  memories  rise  above 
the  threshold  of  consciousness.  As  to  its  physical  nature, 
memor}'  must  be  regarded  as  an  attribute  that  nervous 
matter  possesses  in  common  with  vital  protoplasm  in  general, 
without  which  no  men4;al  progress  could  take  place.  A  nervous 
discharge  proceeds  in  one  direction  onh'  by  what  is  called 
"  forward  conduction  "  and  tends  to  be  facihtated  by  repe- 
tition. As  an  impulse  passes  from  one  neuron  to  another 
it  ingrains  itself  as  memory  or  neural  habit,  each  discharging 
impulse  leaving  its  mark  or  impression  upon  the  connect- 
ing sjTiapses,  and  diminishing  their  subsequent  powers  of 
resistance. 

Disorders  of  Memory. — («)  Amnesia,  or  loss  of  memor3\ 
This  may  be  :  (1)  partial,  as  in  the  inability  to  recall  names 
in  Old  Age,  and  in  Aphasic  conditions;  (2)  progressive,  as 
in  General  Paralysis  and  chronic  mental  disorders  tending 
to  Dementia ;  (3)  temporary,  as  in  Epilepsy,  Acute  Delirious 
Mania,  and  after  shock  or  injury ;  or  (4)  periodic,  as  in  states 
of  Double  Consciousness,  Somnambulism  and  Hypnosis. 

(6)  Hyyermnesia,  or  exaltation  of  memory,  is  witnessed 
in  some  cases  of  Acute  Mania,  and  occasionally  in  febrile 
conditions  and  in  poisoning  by  Cannabis  Indica  and  other  drugs. 

(c)  Paramnesia,  or  perversion  of  memorj^  with  illusions  is 
common  in  chronic  Alcoholic  conditions  in  which  events  are 


30  MENTAL  DISEASES 

confabulated  that  never  occurred  at  all,  but  are  fixed  in  the 
memory  of  the  patient. 

The  natural  failure  of  memory  occurs  in  the  inverse  order 
of  its  evolution,  memory  for  recent  events  nearly  always 
fading  away  first,  whilst  the  organised  memories  of  the  past 
are  the  last  to  disappear.  The  tendency  to  the  spontaneous 
recurrence  of  past  experiences  (sensory,  motor,  and  ideational), 
is  generally  due  to  inertia  or  fatigue.  This  is  sometimes 
called  perseveration,  and  occurs  frequently  in  the  insane. 


CHAPTER  III  • 

SENSATION,    PERCEPTION,    AND    IDEATION 
(COGNITION) 

Sensation  is  the  mental  process  resulting  from  the 
assimilation  of  impressions  from  surrom.idmgs.  In  an  animal, 
possessing  a  brain,  with  the  elements  of  feeling,  this  central 
organ  is  the  highest  receptive  mechanism  by  which  molecular 
energy  received  by  the  animal  is  distributed  according  to  its 
needs.  This  energy  is  derived  from  peripheral  sense  organs, 
and  in  great  measure  from  the  alimentary  tract  and  viscera  by 
means  of  the  s^rmpathetic  nervous  system. 

All  mental  processes  may  be  said  to  be  dependent  on  sen- 
sory impressions  affecting  us  from  within  and  from  without. 
From  sensations  spring  our  perceptions,  feeUngs,  and  higher 
psychic  processes. 

Every  sensation  is  composed  of  at  least  four  attributes, 
viz.  :  (1)  its  quality,  dependent  on  the  particular  sensory  neuron 
stimulated,  which  is  largely  determined  by  the  character  of  the 
cortical  tract  affected:  e.g.  electrical  stimulation  of  the  tongue 
produces  sensation  of  taste ;  sudden  pressure  on  e^^eball  pro- 
duces sparks  of  light.  This  is  in  accordance  with  Mueller's  doc- 
trine of  the  specific  energies  of  sensory  nerves.  But  it  must  be 
noted  that  certain  external  stimuli  produce  different  sensa- 
tions :  e.g.  colour  is  dependent  on  wave-lengths,  as  is  also  the 
pitch  of  sounds.  (2)  Its  intensity — i.e.  strength  of  stimulus. 
Just  noticeable  sensations  vary  with  the  different  sense  organs  : 
usually  sight  being  1  candle  power  in  100,  sound  1  in  3,  and 
weight  (muscular  sense)  1  in  17.  The  Weber-Fechner  law 
formulates  that  a  sensation  increases  as  the  logarithm  of  the 
stimulus, 

(3)  Its  duration — i.  e.  its  relation  to  time,  or  the  uiterval 
between  the  stimulus  and  the  cessation  of  sensation. 

31 


32  MENTAL   DISEASES 

(4)  Its  extent — i.  e.  its  relation  to  space,  which  is  most 
marked  in  the  senses  of  touch  and  sight. 

These  attributes  may  be  considered  the  elements  of  cogni- 
tion, and  are  the  roots  from  which  the  higher  mental  processes 
of  perception  and  ideation  spring.  Affection,  or  the  element  of 
feeling,  is  sometimes  regarded  as  a  fifth  attribute  of  sensation. 
It  is  more  correct  to  regard  it  as  being  concerned  with  all  the 
foregoing  attributes  and  as  being  probably  as  fundamental  as 
is  sensation.  Herbert  Spencer,  indeed,  considered  feeling  as 
the  primary  element  of  mind  and  the  cognitive  element  as 
a  relation  between  feelings. 

Sensations  are  divided  into  the  special  sensations,  viz.  those 
derived  from  the  five  special  senses,  the  sixth  or  kinsesthetic 
sense,  and  the  organic  or  visceral  sensations — the  last  being 
to  some  extent  primordial  and  associated  with  the  essential 
cravings  or  desires  of  the  individual. 

There  is  no  essential  distinction  between  a  special  and 
organic  sense,  the  latter  having  end  organs  comparable  to 
those  of  the  former,  and,  when  disordered,  radiating  sensa- 
tions in  skin  areas  (referred  pains)  in  accordance  with  the  spinal 
segmental  distribution.  All  sensations  are  evolved  from  the 
primeval  irritability  of  protoplasm  and  are  derived  from  the 
sensibility  of  end  organs.  There  are  probably  not  more  than 
a  hundred  elementary  qualities  of  sensations.  The  fusion  of 
sensations  in  which  the  massive  organic  sensations  largely  pre- 
dominate, forms,  as  it  were,  the  background  of  Consciousness. 

Special  Sensations. — (1)  Hearing  :  due  to  vibrations  of 
air  (16  per  sec.  to  30,000  per  sec.)  on  the  cochlea,  which  contains 
probably  about  50  end  organs — producing  pitch  and  tone  of 
sound. 

(2)  Sight :  due  to  vibrations  of  the  ether,  causing  chemical 
changes  in  the  rods  and  cones  of  the  retina,  which  give  rise  to 
light  and  colour.  The  fovea  centralis  is  entirely  composed 
of  cones  which  are  of  three  kinds  for  the  primary  colours,  red, 
green  and  blue,  and  their  composite  white,  and  its  negative 
black.  The  rods  only  function  in  dim  light  and  then  produce 
a  grey  sensation. 

(3)  Taste  :  due  to  chemical  action  of  various  substances  on 
the  taste  organs — producing  sw^eet  (tip  of  tongue),  bitter 
(back  of  tongue),  salt,  and  sour  sensations. 


SENSATION,   PERCEPTION,   AND   IDEATION      33 

(4)  Smell :  due  to  chemical  action  of  particles  reacting  on 
the  Schneiderian  membrane .  About  a  dozen  essential  qualities 
of  smell  can  be  differentiated,  probably  dependent  on  differences 
in  the  end  organ,  and  their  fusion  results  in  the  variety  of 
olfactory  sensations. 

(5)  Skin  .--due  to  mechanical  and  other  stimuli  on  different 
end  organs,  producing  sensations  of  (a)  touch  and  light  pressure, 
(6)  pain,  (c)  heat,  (d)  cold. 

Head's  investigations  demonstrate  that  the  skin  is  supplied 
with  fibres  from  the  "  protopathic  "  nerve  system  (allied  to 
the  sympathetic)  as  well  as  mth  specific  localising  or  "  epicritic  " 
fibres. 

ORGANIC   SENSATIONS. 

(6)  Kinesthetic.  (sense  of  posi- 

Muscular  sensations  .  \  tion  and  move-   (  due  to  contraction  or  pressure. 
Tendinous  sensations  r  ment,  deep  sensi-  -   due  to  stretching 
Articular  sensations    J  bility  to  pressure  [  due  to  pressure, 
and  pain) 

(7)  Static    .....     (pose  of  body)       .      due  to  alterations  in  pressure 

of  the  labyrinthine  fluid. 

(8)  Visceral,  etc.  (largely  from  vagus    and 

sjonpathetic  system) 

Circulatory due  to  blood  tension,  etc. 

Respiratory due  to  amount  of  CO^  or  irri- 
tating bodies. 

Urinary  ...  .......     due  to  bladder  distension,  etc. 

Sexual  duetoactivity  of  sexual  glands, 

vascular  and  muscular  con- 
tractions. 

Alimentary  .  (hunger,  thirst,  etc.)  .  pharyngeal,  oesophageal,  gas- 
tric, intestinal,  rectal  due 
to  peristalsis,  distension, 
etc.,  also  influence  of  liver 
and  other  glands. 

Assimilatory      .     (coensesthesis)     .     .     .     due     to     metabolism     of     the 

tissues  generally. 

The  Physical  Substrata  for  Sensation  consist  of  the 
afferent  projection  areas  of  the  cortex  (Figs.  15  and  16).  It  is 
probable  that  the  ultimate  cause  of  the  difference  in  sensations 
is  due  to  a  specific  biochemical  constitution  of  the  various 
sensory  cortical  neurons. 

The  follomng  sensory  distribution  may  be  specified : — 

Visual  (half -field).     The  calcarine  area  of   the  occipital   lobe 
marked  by  the  line  of  Gennari. 

D 


34  MENTAL   DISEASES 

Auditory.  The  first  temporo-sphenoidal  convolution,  es- 
pecially its  Sylvian  portion — the  gyri  of  Heschl. 

Olfactory.     The  pyriform  portion  of  the  limbic  lobe. 

Taste.     Adjacent  to  the  olfactory  portion. 

General  Sensation  (touch,  kinsesthetic  sensation,  and  possibly 
visceral  sensations,  etc.).  The  anterior  part  of  the  as- 
cending parietal  convolution. 

In  their  afferent  path  all  sensory  impressions  pass  through 
the  thalamus,  which  may  be  regarded  as  a  relay  station,  where 
especially  the  visceral  impressions  are  represented,  and  where 
fusion  occurs  with  impressions  from  the  special  sense  organs. 
Experiments  have  shown  that  the  thalamus  is  sensitive  to 
pain  (unlike  the  cortex),  and  it  may  possibly  be,  as  Head 
suggests,  a  co-ordinating  centre  for  subconscious  affective 
states. 

Disorders  of  Sensation. — These  occur  usually  as  :  (1) 
Diminution  of  sensation,  or  as  (2)  Excess  of  sensation.  (The 
so-called  sense  perversions,  such  as  illusions  and  hallucinations, 
involve  a  higher  mental  operation  and  are  described  later.) 

Stuporous  and  Demented  patients  exhibit  a  certain  amount 
of  analgesia  and  anaesthesia  of  skin,  as  evoked  by  the  prick  of 
a  pin.  This  is  especially  marked  in  Confusional  cases,  and 
Stoddart  has  pointed  out  that  it  may  be  complete  with  the 
exception  of  the  genital  area  and  the  soles  of  the  feet.  Hearing 
is  defective  in  Dements  and  sometimes  in  General  Paralytics. 
Deafness  in  itself  predisposes  to  insanity,  as  it  often  leads  to 
the  growth  of  suspicions  and  the  development  of  auditory 
illusions  and  hallucinations.  Sight  is  weakened  in  Melan- 
choliacs  and  in  some  Dements,  whilst  contraction  of  the  field 
of  vision  occurs  in  Hysterical  and  Confusional  cases.  Taste 
and  smell  are  defective  in  Dementia,  in  Confusional  cases,  and 
in  the  later  stages  of  General  Paralj^sis.  The  sexual  sensa- 
tions are  in  abeyance  in  Melancholia  and  in  many  cases  of 
Dementia,  whilst  in  other  Dements  and  Aments  they  are 
abnormally  active  from  a  dearth  of  higher  mental  processes. 
The  alimentary  sensations  are  diminished  in  Melancholia, 
whilst  loss  of  appetite  is  common  in  many  chronic  psychoses, 
but  only  occasional  in  General  Paralysis.  All  the  senses  are 
hyperactive  in  Acute  Mania. 


SENSATION,   PERCEPTION,   AND   IDEATION      35 

Perception  is  the  cognitive  process  by  which  a  person 
becomes  aware  of  definite  objects  in  his  environment.  A 
perception  is  therefore  a  presentation  in  consciousness  of  an 
external  object.  It  is  derived  from  sensations  and  their 
relations  to  objects,  and  involves  memories  of  previous  sensa- 
tions which  are  residua  of  a  like  character.  It  has,  associated 
with  it,  also  a  corresponding  tone  of  feeling.  The  pen  I  hold 
gives  me  the  perception  of  a  pen  involving  sensations  of 
sight,  touch,  and  of  the  kinaesthetic  sense,  and  calling  up  also 
memories  of  past  similar  sensations  and  perceptions  {recogni- 
tion). The  term  Apperception  is  sometimes  applied  to  the 
central  focus  of  perception  in  Consciousness,  which  involves 
the  process  of  attention  in  particular  (vide  p.  67). 

Perceptions  of  whatever  sense  have  relation  to:  (1)  Quality 
(and  intensity),  (2)  Space,  and  (3)  Time. 

Perceptio7i  of  Quality  arises  from  the  fusion  of  sensations 
derived  from  external  objects  and  from  previous  experience 
of  the  same.  Stereognosis  is  the  term  applied  to  the  per- 
ception of  form  and  consistency  as  derived  from  the  kin- 
sesthetic  and  tactile  senses.  The  visual  organ  assists  to  a 
certain  extent  also  by  means  of  its  stereoscopic  property. 

Perception  of  Space  is  mostly  obtained  from  the  senses 
of  touch  and  sight,  combined  with  the  kinsesthetic  sense.  An 
infant  learns  to  miderstand  distance  by  tactile  experiments 
at  first,  and  binocular  vision  is  an  additional  aid  later.  In 
determining  localisation  in  space  there  are  also  what  are 
called  local  signs  in  sense  perceptions,  which  have  been  speci- 
ally^ investigated  by  Lotze.  These  are  due  to  the  different 
areas  of  the  sense  organs  possessing  unequal  sensibility : 
e.  g.  in  the  skin  and  in  the  retina.  In  the  latter  case  the 
associated  areas  stimulated  are  connected  with  kinsesthetic 
impressions  from  the  ocular  muscles,  and  their  correlation 
is  of  importance  in  the  estimation  of  space.  Orientation  or 
the  localisation  of  the  body  in  space  is  due  to  all  the  sense 
perceptions,  but  especially  to  the  perception  of  differences  in 
pressure  of  fluid  in  the  labyrinth  (Static  perception). 

Perception  of  Time  is  derived  from  intermittance  of 
stimulation  of  the  sensory  organs  by  which  intervals  are 
recognised,  and  is  largely  developed  from  the  sense  of  hearing. 
Orientation  is  also  frequently  spoken  of  with  regard  to  the 


36  MENTAL   DISEASES 

perception  of  Time,  and  Disorientation  to  the  corresponding 
disorder  of  perception  either  in  Space  or  Time. 

The  Physical  Substrata  for  Perception. — The  asso- 
ciation areas  of  the  cortex  which  border  on  the  afferent 
projection  areas  constitute  the  substrata  for  perception.  The 
perceptive  centres  may  indeed  be  said  to  radiate  from  their  sen- 
sory progenitors  (Figs.  15  and  16).     They  consist  as  follows  : — 

Visual  (half -field).     The  cuneus  portion  of  the  occipital  lobe. 

(Not  the  angular  gyrus  as  hitherto  believed.) 
Auditory.     The  second  temporo-sphenoidal  convolution. 
Olfactory.     Part  of  the  limbic  lobe. 
Taste.     Adjacent  to  olfactory. 
Touch  discrimination  (epicritic),  Kincesthetic  (Static,  Visceral  ?) 

Posterior  part  of  ascending  parietal  convolution. 

Disorders  of  Perception. — These  consist  of  :  (1)  Diminu- 
tion of  perception,  or  imperception ;  (2)  Excess  of  or  hyper- 
perception  ;  and  (3)  Perversion,  viz.  illusions  and  hallucinations. 

By  imperception,  or  as  it  is  sometimes  called,  agnosia,  is 
meant  that,  although  the  various  special  sense  stimuli  arouse 
sensations,  perception  does  not  occur.  Thus  a  pen  presented 
arouses  visual  sensations  of  the  object,  but  the  patient  does 
not  perceive  what  it  is.  It  also  produces  sensory  apraxia  (vide 
p.  65).  It  has  been  suggested  as  being  due  to  dissociation  b}" 
increase  of  resistance  in  the  connecting  sjTiapses  between  the 
sensory  and  the  perception  areas,  and  is  commonly  observed 
in  toxic  states.  Word-blindness  (alexia)  and  word-deafness, 
which  occur  in  sensory  aphasia,  are  examples  of  imperception, 
the  person  seeing  and  hearing  words  which  to  him  have  no 
meaning,  owing  to  lesions  of  the  auditory  and  visual  perception 
areas. 

Increased  activity  of  perception  occurs  in  acute  disorders 
and  not  infrequently  leads  ultimately  to  perversion  of 
perception. 

An  illusion  is  a  perversion  or  misinterpretation  of  per- 
ception, i.e.  it  is  a  false  or  erroneous  perception  aroused  by  a 
sensation.  The  peripheral  stimulus  gives  rise  to  an  abnormal 
perception,  e.  g.  when  a  patient  sees  a  man  in  the  garden  and 
mistakes  the  man  for  a  cow,  or  hears  the  rustling  of  leaves 
which  he  misinterprets  and  erroneously  perceives  as  a  "voice." 


SENSATION,   PERCEPTION,   AND   IDEATION      37 

All  hallucination  is  a  false  perception  which  is  aroused 
without  any  sensation  whatever.  It  is  a  complete  sense  decep- 
tion, and  there  is,  in  fact,  no  corresponding  peripheral  stimulus 
at  all.  Thus  a  patient  sees  "  visions  "  and  hears  "  voices  " 
that  are  projected  and  have  no  existence  in  reality. 

Dissociation  by  increased  synaptic  resistance,  localised  in 
area,  again  affords  the  best  explanation  for  the  existence  of 
illusions  and  hallucinations.  But  in  the  formation  of  illusions 
there  is  a  circuitous  and  faulty  connexion  with  sensory  stimuli, 
whereas  in  hallucinations  there  are  no  peripheral  stimuli  what- 
ever. In  the  latter  case,  the  hyperactive  sensor}^  areas  are 
evoked  into  consciousness  spontaneously,  or  they  may  arise 
from  abnormal  association  currents  by  a  system,  as  it  were,  of 
cross  working  from  other  areas  which  are  in  connexion.  In 
both  instances  the  association  areas  are  disturbed  as  in  the 
delusional  process  described  later.  It  has  been  argued  that 
hallucinations  are  at  bottom  but  illusions,  for  but  rarely  can 
sensory  stimuli  be  considered  as  really  absent  altogether.  In 
both  illusions  and  hallucinations  there  is  generally  disturbance 
of  the  sensory  areas  as  well  as  of  the  association  areas ;  the 
conditions  must  be  regarded  as  dependent  on  general  neuronic 
instability,  and  there  is  no  essential  difference  between  them. 
In  many  cases  there  is  disorder  of  peripheral  sense  organs 
acting  as  a  chronic  irritant  leading  to  disturbance  of  brain 
functions.  Hallucinations  and  illusions  occur  both  in  the  sane 
and  the  insane,  but  the  judgment  of  the  former  is  not  impaired 
thereby.  The  sane  man  is  able  to  discriminate  between  a 
phantasy  or  "voice  "  and  reality,  which  the  insane  patient, 
having  his  other  senses  to  some  extent  involved  in  the  morbid 
process,  is  unable  to  do. 

Hallucinations  may  be  simple,  such  as  a  flash  of  light  or  a 
sound ;  or  compound,  such  as  a  "  vision  ' '  or  an  imaginary  conver- 
sation. So-called  recurrent  sensations  are  in  reality  hallucina- 
tions, which  affect  some  people  whose  perceptive  centres  become 
temporarily  disordered  by  the  fatigue  of  repeated  stimulation, 
e.  g.  a  tune  of  music,  etc.  They  are  closely  allied  to  after  sensa- 
tions or  images,  which  sometimes  continue  immediately  after 
a  stimulus  has  been  withdrawn  and  are  due  to  inertia. 

Secondary  Hallucinations  (sometimes  called  secondary  sensa- 
tions) are  those  that  are  aroused  by  the  stimulation  of  another 


38  MENTAL   DISEASES 

sense  organ.  Thus,  a  sound  may  be  accompanied  by  a  par- 
ticular colour  (sound  photiSm). 

Illusions  are  common  enough  in  the  sane  and  are  classified 
as  :  (1)  Active,  or  due  to  expectancy,  i.  e.  a  person  sees  and  hears 
what  he  expects,  thus  leading  to  mistakes  of  identity.  This 
occurs  frequently  in  Senile  dotage.  (2)  Passive,  or  due  to 
external  conditions,  e.g.  the  refraction  of  water  gives  the  impres- 
sion of  a  partially  immersed  stick  being  bent ;  night  travelling 
by  train  often  gives  the  idea  of  proceeding  in  the  reverse  direc- 
tion ;  an  object  felt  between  crossed  fingers  gives  the  impression 
of  being  two  objects. 

Hallucinations  occur  in  various  mental  disorders,  especially  of 
the  Confusional  type,  and  when  chronic  they  are  usually  of  bad 
import  in  prognosis.     They  occur  in  about  50  %  of  the  insane. 

Auditory  Hallucinations . — The  ear  is  the  most  compli- 
cated sense  organ,  and  the  perceptions  derived  therefrom  are 
prone  to  be  disordered  in  the  insane.  The  patient  may  be 
subject  to  simple  noises,  or  to  the  deeper  complex  of  a  whispered 
word  or  sentence,  or  of  loud  "  voices."  Sometimes  the  disorder 
is  produced  through  one  ear  only,  and  is  projected  by  the  patient 
from  afar,  or  it  may  appear  to  come  from  within  the  head  or 
from  the  abdomen.  The  "voice"  may  be  of  either  sex,  and 
more  than  one ' '  voice  ' '  may  be  heard.  ' '  Voices  ' '  occur  more  by 
night  than  by  day.  They  are  commoner  in  deaf  patients  than 
in  others.  They  may  be  pleasant  or  mipleasant.  Sometimes 
they  dominate  the  life  of  a  patient  and  are  of  a  command- 
ing nature,  so  that  such  a  patient  is  frequently  dangerous. 
"  Voices  "  occur  mostly  in  Alcoholic,  Paranoiac,  and  Dementia 
Prsecox  patients,  but  also  in  General  Paralysis,  in  Confusional 
and  other  insanities. 

Visual  Hallucinations. — These  are  also  commoner  by  night 
than  by  day,  and  sometimes  occur  in  ordinary  people  when 
waking  from  sleep.  They  are  not  so  frequent  in  the  in- 
sane as  are  auditory  hallucinations.  They  may  occur  in  the 
blind.  Faces  are  seen,  or  a  complete  land-  or  sea-  scape  may  be 
described,  by  the  patient.  They  are  common  in  Alcoholic 
and  Drug  conditions.  Vermm,  beetles,  devils,  or  goblins  of 
a  terrifying  nature,  are  frequently  seen  by  a  patient  suffering 
from  Delirium  Tremens. 

Hallucinations  of  Taste. — These  are  generally  of  an  unpleas- 


SENSATION,   PERCEPTION,   AND   IDEATION      39 

ant  character.  Food  tastes  disagreeably  or  even  filthy  and  the 
patient  has  delusions  of  being  poisoned  and  refuses  to  eat. 
Strictly  speaking,  illusions  are  present  and  the  taste  sensation, 
or  rather  perception,  is  perverted.  In  most  cases  there  is  an 
unhealthy  condition  of  the  mouth  and  alimentary  tract.  Many 
cases  are  associated  with  olfactory  hallucinations. 

Hallucinations  of  Smell. — These  are  usually  of  a  disagree- 
able nature,  but  not  invariably  so.  It  is  noteworthy  that  they 
occur  most  frequently  in  patients  with  sexual  disorders  or  with 
delusions  connected  with  the  reproductive  organs. 

Hallucinations  of  Touch,  Pain,  and  Temperature. — Some 
Alcoholic  and  Paranoiac  cases  complain  of  feeling  insects  crawl- 
ing about  them ;  or  that  currents  of  electricity  or  magnetism 
are  played  upon  them ;  or  that  neuralgic  pains  are  produced 
by  unseen  agencies.  Others  have  thermal  hallucinations,  and 
"  sensations  "  associated  with  the  sexual  organs  or  with  the 
alimentary  tract. 

Organic  and  Visceral  Hallucinations. — These  are  usually  per- 
versions or  misinterpretations  of  organic  sensations,  or,  strictly 
speaking,  they  are  illusions.  They  occur  more  especially  in 
regard  to  the  digestive  tract,  e.g.  the  so-called  epigastric  or 
abdominal  sensation ;  but  they  also  include  hallucinatory 
dysphagia  and  dyspnoea,  besides  various  hallucinations  or 
illusions  from  the  generative  organs.  These  visceral  sensa- 
tions must  be  regarded  as  being  due  to  a  great  extent  to 
radiations  into  the  skin  areas. 

Hallucinations  and  illusions  also  occasionally  occur  in 
connexion  with  Kinaesthetic  and  Static  perceptions. 

Ideation  is  the  process  concerned  with  the  highest  cognitive 
functions  and  comprises  Thought  and  Intellect,  and  it  involves 
the  operation  of  Memory  in  particular.  An  idea  of  an  object 
is  derived  from  the  memories  of  past  perceptions,  or  what  are 
sometimes  called  memory  images  or  re-presentations  of  an 
object.  It  also  produces  a  corresponding  complex  subjective 
feeling  of  pleasure  or  the  reverse,  which  we  call  Emotion.  The 
idea  of  a  "  pen,"  for  instance,  is  based  upon  the  memory  images 
or  the  memories  of  perceptions  of  a  pen  in  the  past.  Most 
people,  in  forming  ideas  of  any  particular  object,  find  that  the 
memory  of  one  sense  preponderates  over  another.  Thus,  it  may 
be  chiefly  visual,  i.  e.  seeing  the  name  or  symbol  given  to  the 


40  MENTAL   DISEASES 

object  written  or  printed;  or  it  maybe  chiefly  auditor}^,  i.  e. 
hearing  it  pronounced.  It  involves  also  subconscious  articular 
kinsesthetic  movements,  without  which  concentrated  Thought 
or  Conception  is  scarcely  possible.  It  might  here  be  mentioned 
that  some  psychologists  ascribe  the  essential  characteristics 
of  cognition  in  all  mental  processes  as  being  due  to  what  they 
call  "meaning,"  implying  thereby  a  quasi-metaphysical  link 
between  impressions  and  reactions. 

Ideas,  like  perceptions,  have  attributes  such  as  quality,  *.  e. 
their  essential  nature,  and  intensity,  i.e.  their  vividness,  and  to 
some  extent  they  also  have  spatial  and  temporal  relationships 
through  the  memory  of  past  perceptions.  Ideas  maybe  simple 
or  compomid.  By  a  process  of  mental  abstraction,  the  qualities 
of  different  ideas  can  be  considered  apart,  and  the  result  is 
what  is  termed  a  concept.  Thus  the  colour  Red  is  a  concept, 
and  is  derived  from  ideas  which  are  the  result  of  perceiving  red 
objects. 

The  Association  of  ideas. — One  idea  according  to  its  emo- 
tional tone  tends  spontaneously  to  call  up  another  idea,  either 
at  once,  or  after  an  appreciable  interval  of  time — in  other  words, 
the  association  may  be  simultaneous  or  successive.  This 
association  of  ideas  occurs  in  the  process  of  thought,  and  is 
subject  to  the  ordinary  laws  of  causation,  one  idea  calling  up 
another  by  some  definite  link  which  should  occur  in  orderly 
sequence  in  the  logical  thinker.  Mental  energy  is  thus  expended 
in  ideational  association  or  a  train  of  thought,  or  it  results  in 
action,  volitional  or  otherwise. 

Certain  associated  ideas,  however,  according  to  their  emo- 
tional tone,  tend  to  conglomerate  together  into  what  has  been 
termed  a  "  complex,"  or  system  of  emotionally  toned  ideas 
(Hart).  Thus  the  political  or  religious  creed  that  a  person 
professes  is  largely  due  to  complexes  based  on  feelings  and  ideas 
acquired  by  suggestion,  rather  than  by  reason.  A  complex  will 
either  reciprocate  or  antagonise  with  other  complexes ;  in  the 
latter  case  there  results  what  is  known  as  conscious  or  sub- 
conscious "conflict,"  —  that  frequent  precursor  of  mental 
disturbance. 

The  human  brain  has  gained  the  advantage  over  that  of  the 
lower  animals  in  the  greater  development  of  its  association 
areas  and  thereby  superior  capacity  for  thought  and  volition. 


SENSATION,   PERCEPTION,   AND   IDEATION      41 

The  commonplace  brain  has  circumscribed  association  areas, 
the  average  brain  has  broader  areas,  whilst  the  man  of 
superior  intelligence  owes  it  to  their  quality  and  greater 
development,  their  apotheosis  being  reached  in  the  man  of 
genius.  According  to  Clouston's  speculations,  four  out  of 
every  five  individuals  may  be  regarded  as  possessing  average 
intelligence,  1  in  11  is  specially  talented,  1  in  450  is  a  lesser 
genius,  of  genius  itself  only  a  few  examples  occur  in  a  genera- 
tion, 1  in  450  is  eccentric,  and  1  in  11  is  markedly  under  the 
average.  One  method  of  estimating  the  mental  calibre  of 
an  individual,  so  far  as  ideas  are  concerned,  is  the  vocabulary 
that  he  possesses.  A  man  of  low  intelligence  uses  only  about 
300  different  words,  the  ordinary  person  uses  about  1500, 
whilst  Shakespeare  is  credited  with  using  over  15,000. 

Laws  of  association  have  been  formulated  according  as  to 
whether  the  association  of  ideas  occurs  by  similarity,  by 
contiguity,  or  by  contrast,  in  time  or  in  space.  In  a  state  of 
dream  reverie  or  phantasy,  the  associations  adopt  a  quasi- 
haphazard  course  because  they  are  mthout  the  control  of 
voluntary  attention.  This  occurs  also  in  the  lighter  degrees 
of  Sleep,  Delirium,  Confusional  insanity,  and  Mania.  In 
following  a  logical  train  of  thought,  the  process  of  attention 
— which  is  described  later^ — has  to  be  called  into  play  to  co- 
ordinate ideas  further,  and  as  with  all  ideation,  this  requires  the 
aid  of  the  faculty  of  memory. 

Imagination  is  the  power  of  making  associations  from 
concepts  as  well  as  from  ideas,  and  is  therefore  specially  de- 
pendent on  memory.  It  may  be  :  (1)  Reproductive,  from  the 
past  experience  of  the  individual ;  or  (2)  Constructive,  in  the  form- 
ation of  novel  associations  of  a  high  order,  which  occurs  in  the 
artist,  inventor,  or  man  of  genius.  Imagination  is  called 
into  play  largely  by  those  richly  endowed  with  the  sesthetic 
sentiments. 

Judgment  and  Reasoning. — A  judgment  is  a  process  of 
deliberation  in  which  a  relation  is  formed  in  the  association 
of  ideas,  which  is  sometimes  also  called  discrimination,  com- 
parison, or  the  sense  of  proportion.  When  accompanied  by  an 
excess  of  affective  tone,  a  judgment  becomes  a  "  Belief,"  and, 
strictly,  should  be  regarded  as  a  Sentiment.  In  the  process  of 
forming  a  judgment,  an  abstraction  of  a  certain  quality  is  made 


42  MENTAL  DISEASES 

from  one  concept  or  idea  and  is  re-combined  with  another. 
In  Stoddart's  words — a  judgment  is  an  association  after  dis- 
junction, and  is  really  a  special  form  of  association.  When  a 
judgment  is  expressed  in  words  it  is  called  a  proposition. 

Reasoning  consists  of  a  still  higher  association,  namely  the 
relation  of  judgments  or  propositions  and  the  arrival  at 
conclusions  by  deduction.  The  discrimination  between  true 
and  false  deductions  belongs  to  the  science  of  Logic. 

The  Physical  Basis  of  Ideation  lies  in  the  association 
areas  of  the  cortical  convolutions,  the  perceptive  areas  merging 
into  the  ideational  substrata  (Figs.  15  and  16).  All  ideation  is 
dependent  on  neural  association ;  each  association  area  has 
connexions  by  fibres  with  the  other  association  areas,  and  by 
means  of  commissural  fibres  through  the  corpus  callosum  with 
those  of  the  opposite  hemisphere,  and  with  the  perceptive 
centres  on  the  afferent  path  and  with  the  motor  region  on  the 
efferent  by  means  of  the  ideomotor  centres  in  the  Frontal 
lobe. 

Disorders  of  Ideation. — (I)  Absence  of  Ideas.  This  may 
be  due  to  inertia  or  functional  dissociation  of  ideas,  as  in 
Stupor,  and  is  evidenced  by  apathetic  Mutism  in  many 
cases  of  Melancholia  and  Dementia  Prsecox ;  or  it  may  be 
organic,  as  in  profound  Amentia  and  Dementia. 

(2)  Retardation — i.  e.  a  slowing,  wandering,  or  difficulty 
in  the  association  of  ideas,  which  occurs  in  Melancholia  and 
other  conditions  of  depression.  This  is  largely  dependent 
on  toxins  paralysing  or  functionally  destrojdng  neuronic 
connexions,  but  it  also  arises  from  incomplete  development  of 
neurons,  and  sometimes  from  peripheral  anaesthesia. 

(3)  Acceleration  of  Ideas  :  from  too  rapid  association,  as 
in  the  preliminary  stages  of  Alcoholism  or  in  Mania.  It 
leads  in  some  cases  to  the  so-called  Flight  of  Ideas  on  a  lower 
level  than  is  normal. 

(4)  Obsession  of  Ideas  occurs  in  Psychasthenia,  in  which 
imperative  ideas  constantly  recur  or  are  fixed  and  cannot  be 
banished  from  consciousness.  It  is  generally  due  to  emotional 
stress,  together  with  defective  volition.  It  frequently  leads  to 
impulsive  or  disordered  conduct. 

(5)  Disorder  of  Sequence  of  Ideas  occurs  as  irrelevance, 
rambling,  confusion,  and  incoherence.     There  is  a  dissociation. 


SENSATION,   PERCEPTION,   AND   IDEATION      43 

or  want  of  logical  connexion  between  ideas,  leading  sometimes 
to  monotonous  repetitions  (Verbigeration),  senseless  rhjTuing, 
or  imitating  the  phrases  of  others  (Echolalia).  Examples  of 
these  are  abundant  in  Confusional  insanity,  Dementia  Prsecox, 
and  Paranoia.  They  are  witnessed  both  b}^  the  speech  and 
the  writing  of  patients. 

Delusions. — These  are  false  beliefs  or  errors  in  judgment 
which  defy  correction  and  are  beyond  argument,  being  de- 
pendent on  faulty  association  of  ideas.  Although  common  in 
the  insane  and  of  great  importance  from  the  legal  standpoint, 
insanity  occurs  without  delusions,  and  delusions  occur  in 
persons  otherwise  sane.  In  estimating  a  delusion,  the  class  of 
life  of  a  person  must  be  taken  into  account,  in  conjunction  with 
his  education  and  his  general  environment.  Many  delusions 
are  based  on  illusions  and  hallucinations,  as  evinced  by  conduct, 
and  are  due  to  misinterpretations  of  sensations,  or  rather, 
of  perceptions.  But  for  the  most  part,  they  are  due  to  irra- 
tional or  wrong  ideational  paths  and  are  the  outcome  of  a 
dissociated  confusional  state  of  the  subconscious  life,  caused 
by  disordered  feeling  or  emotion,  that  seeks  expression. 
Such  disorder  sometimes  leads  to  the  development  of  illusions 
and  hallucinations  only. 

Delusions  in  their  development  are  concerned  either  Avith 
the  person  expressmg  them,  or  with  the  surroiuidings  of  the 
person.  Li  the  former  case  the  whole  self  may  be  impli- 
cated, such  as  (1)  a  state  of  depression  with  ideas  of  morbid 
apprehensiveness,  of  impending  evil,  of  being  incapacitated, 
inefficient,  unworthy  or  unnatural,  of  being  ruined  financially 
or  morally,  of  being  wicked,  of  having  committed  imaginary 
crimes  or  the  "  unpardonable  sin,"'  of  having  lost  the  soul,  of 
being  eternally  damned  and  with  other  self -accusatory  notions ; 
or  (2)  a  state  of  exaltation  in  which  the  patient  has  ideas  that 
he  is  the  Deity,  the  King,  or  a  Duke,  that  he  is  a  millionaire, 
that  he  is  the  strongest  or  cleverest  man  in  the  world,  that 
he  is  an  artistic  genius,  or  that  he  is  engaged  or  married  to 
a  princess,  etc.  Part  of  the  self  only  may  be  affected  in  the 
morbid  process,  causing  (3)  visceral  or  bodily  delusions.  Thus 
a  patient  may  think  he  has  no  brain,  or  no  limbs,  that  his 
legs  are  made  of  glass,  that  his  body  is  hollow,  that  his  throat 
is  blocked  up,  that  his  bowels  are  obstructed,   or  that  his 


44  MENTAL   DISEASES 

sexual  nature  is  ruined,  etc.  Delusions  regarding  a  person's 
surroundings  are  especially  apt  to  develop  in  any  one  mth  a 
suspicious  temperament ;  they  consist  of  (4)  Delusions  of 
suspicion  and  persecution,  by  electricit}"  or  magnetism,  by 
imagining  that  people  make  base  insinuations,  by  the  notion 
of  a  systematic  conspiracy,  in  which  certain  people,  the  police, 
or  the  whole  world  take  part,  by  the  idea  of  being  defrauded 
by  some  one,  by  imaginary  infidelity  of  a  spouse,  b}^  mis- 
taking the  identit}^  or  sex  of  other  people,  or  by  mistaking 
the  nature  of  the  surroundings,  etc.  Some  delusions  are  of 
mixed  origin,  and  implicate  both  the  person  and  his  sur- 
roundings. 

It  is  noteworthy  that  sometimes  bodily  disorder  locates  a 
delusion,  but  then  it  is  the  mental  disorder  which  misinterprets 
the  bodily  sensations,  e.  g.  a  patient  mth  flatulent  dyspepsia 
believes  herself  pregnant,  or  an  aortic  aneurysm  gives  rise 
to  the  idea  that  a  snake  resides  in  the  thorax,  etc.  Finally 
states  of  alternating  and  double  personality  are  in  reality 
delusions  of  self-identit3^ 

The  so-called  delusions  of  the  sane  consist  mostly  of 
fallacies  dependent  on  superstitions  and  want  of  education. 
They  differ  from  insane  delusions  in  that  to  some  extent  those 
who  utter  them  are  amenable  to  argument  and  instruction. 
Examples  are  demonstrable  in  children  and  the  ignorant, 
and  in  those  persons  who  will  not  sit  do^Mi  thirteen  at  dinner 
and  the  like. 

The  ultimate  cause  of  delusions  is  faulty  association  of 
ideas,  resulting  in  dissociation.  This  may  occur  from  a  chronic 
morbid  state  of  the  feelings  for  which  a  patient  seeks  an  ex- 
planation ;  the  retardation  of  ideas  and  painful  emotion  in 
depression  produce  a  splitting  off  of  certain  ideational  com- 
plexes from  the  general  personality,  which  cr3^stallise  out  into 
a  delusion  as  a  saturated  solution  of  grief  (Savage).  If  undue 
elation  occurs  with  mental  buoyancy  and  easy  transference 
of  ideas,  a  patient  begins  to  imagine  himself  a  person  of  wealth 
and  importance.  Should  suspicion  be  a  characteristic,  with 
or  without  either  of  the  foregoing,  the  patient  seeks  an  ex- 
planation in  some  evil  machination  in  the  surroundings.  His 
judgment  and  reasoning  powers  are  also  hindered  perhaps 
by  defects    of    memory,  his    perceptions    of    the    past    seem 


SENSATION,   PERCEPTION,   AND   IDEATION      45 

to  be  unreal,  and  he  adapts  himself  to  a  new  nexus  of 
ideas  in  consonance  \vith  his  existent  disordered  emotional 
state. 

Mention  has  already  been  made  of  the  influence  of  hallucina- 
tions and  illusions  in  the  chain  of  the  creation  of  delusions. 
It  is  probable  that  in  some  instances  the  ideational  areas  are 
thus  secondarily  involved,  this  affection  being  subsequent 
to  the  formation  of  hallucinations.  In  other  cases  the  per- 
ceptive centres  are  aiiected  secondarily,  and  the  disorder 
spreads  from  the  ideational  areas,  causing  illusions  and  halluci- 
nations. The  organic  process  and  phj^sical  substratum  of 
delusions,  illusions,  and  hallucinations,  are  closely  allied  and 
depend  largely  on  the  extent  of  cortex  involved.  Hallucina- 
tions are  not  infrequently  described  as  delusions  affecting  the 
special  senses,  in  contradistinction  to  those  pertaining  to  the 
ideational  centres — or  memories  of  past  perceptions.  In 
both,  the  misinterpretation  is  due  to  faulty  nervous  connex- 
ions leading  to  false  beliefs  which  are  not  amenable  to  argu- 
ment. In  Hypochondriasis  the  afferent  nerve  currents  from, 
the  viscera  are  probably  sometimes  altered  in  intensity,  and 
contribute  to  disturb  the  association  connexions  so  far  as  to 
exaggerate  the  bodily  sensations  and  thus  to  lead  to  delusional 
explanations. 

Delusions  may  occur  in  almost  every  form  of  insanity. 
In  the  acute  stages  of  disorder,  when  they  exist,  they  are  of  a 
fleeting  nature,  whilst  in  chronic  conditions  they  may  change 
from  time  to  time  or  else  they  tend  to  become  fixed.  A 
delusion  does  not  necessarily  implicate  the  conduct  of  a 
patient,  neither  need  it  materially  affect  the  judgment  of  a 
patient  in  matters  outside  the  deluded  train  of  thought.  In 
General  Paralysis  the  most  extraordinary  delusions  may  be 
expressed  of  a  superlative  nature,  whilst  in  Paranoia  the 
delusions  become  systematised  so  that  a  definite  insane  story 
is  evolved,  viz.  that  a  conspiracy  is  being  formed  or  that  the 
patient  is  being  persecuted. 

Many  of  the  insane  are  aware  that  they  are  ill  or  are 
suffering  from  mental  disorder ;  especially  is  this  the  case 
\\dth  Melancholiacs.  When,  however,  delusions  exist,  patients 
for  the  most  part  lose  correct  "  insight  "  into  their  state 
and  are  unable  to  appreciate  their  true  condition ;    the}'"  are 


46  MENTAL   DISEASES 

therefore  apt  to  regard  their  detention  under  care  and  treat- 
ment as  improper  and  unjust.  Jii  recoverable  cases,  as 
improvement  occurs,  delusions  tend  to  fade  away  as  the 
association  currents  approach  the  normal,  and  the  patient 
then  becomes  aware  of  the  erroneous  nature  of  his  former 
ideas.  It  is  therefore  the  endeavour  of  the  physician  to 
estabhsh,  if  possible,  fresh  ideas  and  interests  in  the  patient, 
in  the  hope  that  the  faulty'  association  may  discontinue  from 
disuse. 


CHAPTER   IV 

FEELING,    EMOTION,    AND    SENTIMENT  ^ 

(AFFECTION) 

Feeling  is  the  term  applied  to  the  pleasant  or  unpleas- 
ant subjective  tone  pervading  and  accompanjong  the  mental 
processes  of  sensation  and  elementary  perception. 

In  the  evolution  of  life  the  human  organism,  like  all  others, 
is  subject  to  utilitarian  or  hedonistic  influences,  and  is  attracted 
by  what  is  pleasurable,  and  is  repelled  by  what  is  disagreeable, 
harmful,  or  painful.  Feeling  is  at  the  foundation  of  the 
struggle  for  existence,  and  is  in  accordance  with  the  primal 
laws  of  self-preservation  and  reproduction.  From  the  sub- 
jective state  of  Feeling  arise  all  Emotions.  Desires,  and  Listincts, 
which  at  bottom  largely  actuate  Conduct. 

Whether  Affection — i.  e.  Feeling — be  regarded  as  an  attribute 
of  Sensation,  or  as  the  basis  on  which  Sensation  originates, 
and  affects  the  miity  of  Consciousness,  it  is  in  its  higher  manifes- 
tations, mth  its  complexity  of  sensations,  that  its  interest  to 
the  practical  psychiatrist  lies.  The  feeling  of  pleasure  and 
pain  accompanying  any  sensation  is  largely  due  to,  or  is  aug- 
mented by,  superadded  muscular,  circulatory,  and  other  sensa- 
tions, in  addition  to  the  primary  sensory  stimulus. 

The  positive,  or  pleasurable  tone  of  feeling  in  a  person 
subjected  to  a  certain  stimulus  is  attended  by — 

Dilatation  of  arterioles. 

Deeper  respiration, 

Increased  cardiac  and  muscular  action, 

whilst  in  a  negative  or  painful  tone  of  feeling  the  reverse  takes 
place.  To  a  musical  person  a  harmonious  melod}'  produces 
the  former,  whilst  discordant  noise  produces  the  latter. 

Physical  Substratum  of  Feeling. — As   the   cognitive 

47 


48  MENTAL   DISEASES 

element  of  mind,  which  is  the  feature  of  perception  and 
ideation,  is  principally  derived  from  the  special  senses,  so, 
affective  tone  or  feeling  is  mostly  concerned  with  organic 
sensibility,  and  is  therefore  largely  due  to  impressions  received 
through  the  vagus  and  the  sjonpathetic  system. 

Consciousness  being  composed  of  feelings  as  much  as  of 
perceptions  and  ideas,  central  representation  of  feelings  must 
exist.  In  all  probability  the  cortex  is  thus  stimulated  by  the 
afferent  system  of  neurons  from  the  thalamus.  The  thalamus 
may  be  regarded  as  the  subconscious  mechanism  for  affective 
tone,  the  protopathic  system  terminating  in  its  central  grey 
matter. 

Disorders  of  Feeling. — These  are  due  m  part  to  the  inher- 
ent quality  of  the  nervous  elements  producing  undue  sensitivity 
or  the  reverse.  Excess  or  diminution  of  feeling  may  arise  from 
want  of  cortical  control  over  thalamic  activit}^  but  it  may  also 
to  some  extent  be  dependent  on  a  too  ready  reflex  action  or 
the  reverse.  Sometimes  in  the  insane,  feeling  is  perverted  so 
that  a  painful  state  is  aroused  by  what  should  be  pleasurable 
sensation,  and  vice  versa. 

Emotion  is  the  tone  of  feeling  belonging  to  higher  per- 
ceptions and  ideas.  Pleasure  and  Pain  are  characteristics 
of  emotion  as  they  are  of  feeling.  But  as  feeling  is  associated 
with  elementary  sensations  for  the  most  part,  so,  emotion  is 
connected  with  the  higher  mental  processes  of  perception  and 
ideation.  These  processes  are  attended  with  a  pleasurable 
or  painful  state  of  feeling,  and  frequently  mth  a  subjective 
state,  equipoised  on  the  border-line  between  the  two.  An 
Emotion  is  composed  of  feelings  which  are  associated  with,  and 
largely  augmented  by,  complex  sensations  which  are  reflexly 
and  involuntarily  aroused  by  the  stimulus  of  a  perception  or 
idea.  When  an  emotion  is  intense  and  of  short  duration  it  is 
termed  a  Passion,  whilst  a  lasting  emotion  of  small  or  moderate 
intensitj^  is  called  a  Mood.  When  a  certam  mood  is  the 
habitual  characteristic  of  a  person's  mental  state  it  is  char- 
acterised as  a  Temperament.  The  classical  divisions  of  tem- 
perament are:  (1)  Sanguine;  (2)  Phlegmatic;  (3)  Choleric; 
(4)  Melancholic.  They  are  dependent  on  the  rate  of  reaction 
and  the  depth  of  feeling  exhibited. 

A  real  classification  of  emotions  and  their  allied  passions. 


FEELING,   EMOTION,   AND   SENTIMENT  49 

moods,  and  temperaments  is  scarcel}^  possible,  as  they  vary 
with  the  particular  perceptual  or  ideational  stimuli  which 
are  brought  into  play. 

To  assist  the  student  with  some  enumeration  of  emotional 
states  the  foUomng  may  be  helpful : — 

(1)  Hilarity,  Exhilaration,  Joy,  Delight,  Satisfaction, 
Content,  Hope. 

(2)  Fear,  Terror,  Anxietj",  Apprehensiveness,  Sorrow, 
Grief,  Regret,  Fright,  Humility,  Bashfuhiess. 

(3)  Anger,  Fury,  Hatred,  Envy,  Jealous}^  Suspicion, 
Disdain,  Malice,  Pride,  Vanity,  Conceit,  Ambition. 

(4)  Love,  Tenderness,  Sjonpath}^,  Benevolence,  Esteem, 
Respect,  Veneration. 

In  all  the  above  emotions  some  perception  or  idea  is  found 
to  be  more  or  less  in  evidence  in  a  given  case.  In  other  cases 
the  intensity  of  an  emotion  sometimes  obhterates  the  ideational 
content,  so  that  an  emotion  tends  to  persist  after  the  related 
ideas  have  vanished  from  consciousness.  On  the  other  hand, 
in  obsessional  cases  the  ideas  are  ever  present.  In  the  first 
group  are  the  emotions  commonly  present  in  an  exaggerated 
degree  in  the  elation  of  Simple  Mania ;  in  the  second  group 
those  that  are  intensified  in  states  of  depression  and  Melan- 
cholia ;  in  the  third  those  that  pervade  Acute  Mania  and  Para- 
noia, whilst  in  the  fourth  are  those  connected  with  or  mostly 
derived  from  the  sexual  emotion.  These  groups,  however, 
necessarily  overlap;  for  instance,  jealous}"  might  equally  be 
regarded  as  a  sexual  emotion. 

Associated  ^\^th  a  marked  emotional  state  there  can  usually 
be  observed  a  bodily  expression,  mainly  dependent  on  in- 
voluntary muscular  actions.  This  expression  is  usually 
regarded  as  secondary  to  the  emotion  and  as  a  vent  for  the 
discharge  of  its  energy.  Thus  in  a  depressing  emotion  the 
angles  of  the  mouth  droop,  the  lachrj'mal  glands  generallj^ 
secrete,  the  organic  fmictions  are  sluggish,  movements  are  slow, 
and  a  characteristic  attitude,  inclined  to  flexion,  is  observed ; 
whilst  in  a  state  of  exhilaration  the  reverse  reaction  takes 
place.  Moreover,  if  the  emotion  is  intense  it  tends  to  still 
further  action.  Thus  Anger,  which  is  outwardly  expressed 
by  fixation  of  gaze,  flushing  of  the  face,  tightening  of  the 
lips,  and  clenching  of  the  fists,  is  apt  to  end  in  fight ;  Fear  may 


50  MENTAL   DISEASES 

develop   into    fliglit,  and   the   sexual   emotion   may   find   its 
instinctive  gratification. 

William  James,  however,  regards  the  expression  as  the 
real  cause  of  the  emotion.  Much  ma}'  be  said  in  favour  of  this 
theory  and  it  will  be  referred  to  in  discussing  its  physical 
basis.  It  is  said  that  most  actors  experience  to  some  extent 
the  emotions  they  dramatically  represent.  Properh'  regulated 
emotion  is  helpful  to  the  individual.  Its  energy  should,  how- 
ever, be  expended  in  the  intellectual  sphere  as  far  as  possible, 
rather  than  be  wasted  in  the  lower  expressional  centres.  The 
latter  is  forcibly  illustrated  in  children,  in  neurotics,  and  in 
certain  cases  of  insanit}'.  B}'  self-control  and  education, 
emotional  tension  should  be  dissipated  in  the  higher  centres, 
and  therefore  its  outward  manifestation  is  largely  repressed 
in  the  cultured  classes. 

Physical  Basis  of  Emotion. — As  affection  is  related  to 
sensation,  so  is  emotion  connected  with  perception  and  ideation. 
It  is  a  component  element  of  Consciousness,  and  therefore  it 
must  have  some  cortical  representation.  Fibres  are  said  to 
radiate  to  the  sensory  cortex  from  the  thalamus,  wliich  is 
now  regarded  as  the  subconscious  centre  for  feehng. 

Being  composed  of  complex  feelings,  an  emotion  ma}'  be 
said  to  be  due  to  the  affective  tone  ultimately  derived  from 
sensory  impressions  arising  cliiefly  from  the  \iscera,  glands  and 
musculature,  which  tone  results  from  the  contmuous  stream  of 
energy  passing  up  the  afferent  tract  to  the  thalamus,  and  which 
is  fuialh'  disposed  of  there,  under  the  control  of  the  cortex.  In 
the  process  of  emotion,  especialh-  when  it  is  intense,  further 
changes  occur  in  these  peripheral  impressions  owing  to  its  bodil}' 
expression  (muscular,  etc.).  This  has  been  regarded  as  a  secon- 
dary- efferent  overflow  of  nervous  energy  which  mcreases  the 
afferent  sensory  impressions.  William  James  and  his  school, 
however,  regard  these  expressional  changes  as  the  essential 
peripheral  cause  of  an  emotion  in  which  the  cerebral  memor}' 
of  former  expressional  changes  accompanpng  the  same  emotion 
largely  contributes. 

An  emotion  being  aroused  by  a  percept  or  idea,  there  seems 
no  doubt  that  an  miconscious  reflex  is  established.  It  is  sug- 
gested by  Stoddart  that  the  efferent  path  for  this  reflex  is  not 
by  means  of  the  pj-ramidal  tract  but  through  the  red  nucleus 


FEELING,   EMOTION,   AND   SENTIMENT  51 

of  the  indirect  motor  path  of  Monakow  to  the  motor  neurons 
and  sympathetic  system  subserving  muscular  and  vasomotor 
action  ;  and  that  the  affective  tone  accompanying  the  resulting 
afferent  sensations  augment  the  emotion,  or  on  James's  hypo- 
thesis, cause  the  emotion.  He  observes  that  this  indirect 
motor  path  is  analogous  to  the  pristine  motor  tract  which 
serves  the  actions  of  birds  and  other  lower  vertebrates  that 
have  no  pyramidal  tract,  and  whose  actions  are  purely 
instinctive.  Emotions  may  be  regarded,  for  the  most  part, 
as  being  centrally  excited  by  perceptions  and  ideas,  and  as 
having  a  reflex  mechanism.  As  percepts  and  ideas  are  de- 
pendent on  the  special  senses  which  are  cognitive  rather  than 
affective,  so  emotions  are  associated  with  organic  sensibility 
which  is  affective  rather  than  cognitive. 

Disorders  of  Emotion. — These  occur  from  (1)  Excess  of 
emotion,  (2)  its  Deficiency,  or  (3)  its  Perversion. 

Excessive  Amotion  is  characteristic  of  Mania  with  its  self- 
conceit,  exaltation  and  excitement;  perception  and  ideation, 
being  in  excess,  cause  reflexes  too  readily.  It  is  frequently 
to  be  seen  also  in  Alcoholic  and  Epileptic  insanity  and  in 
General  Paralysis.  Melancholia,  mth  its  exaggerated  fears, 
apprehensions,  self-abasement,  and  painful  depression,  on  the 
other  hand,  is  associated  with  sluggishness  of  mental  processes, 
and  slowness  of  reflex  action.  Paranoia  is  an  example  of 
excess  of  emotion  of  mixed  character  with  its  morbid  elation, 
vanity,  and  suspicion.  Jealousy  is  often  marked  in  women, 
especially  in  the  mental  disorders  of  the  climacteric. 

Deficiency  of  Emotion  occurs  chiefly  in  Dementia  and 
Amentia  where  the  primary  stimulus  of  perception  or  ideation 
is  small  or  non-existent,  but  blunting  of  the  emotions  is  also 
a  feature  of  chronic  Melancholiacs.  In  many  of  these  cases 
the  countenance  is  fixed  in  gloom,  although  the  emotion  has  to 
some  extent  vanished  through  habit. 

Perversion  of  Emotion  occurs  in  certain  persons  in  whom 
stimuli  produce  different  effects  from  those  produced  in  ordinary 
individuals.  Thus  corporal  pmiishment  in  some  sexual  perverts 
produces  joy,  whilst  another  example  of  perversion  of  the 
sexual  emotion  is  the  abnormal  affection  of  a  spinster  for  her 
dog  or  cat. 

It  has  been  suggested,  as  an  hypothesis,  by  the  modern 


52  MENTAL   DISEASES 

school  of  Freud,  that  emotions  originallj^  accompanying  certain 
perceptions  or  ideas  may  be  transferred  as  "  affects  "  to  other 
ideas  or  "  complexes,"  and  that  such  transference  largely 
accounts  for  the  faulty  association  which  produces  delusions, 
illusions,  and  hallucinations. 

Sentiments  are  in  reality  higher  emotions.  They  dif- 
fer from  the  emotions  already  described  in  that  voluntary 
reactions  involving  attention  and  judgment  come  into  play. 
There  is  in  fact  an  analysis  of,  or  comparison  between,  the 
ideational  and  emotional  processes  in  which  the  latter  become 
modified,  so  that  in  the  higher  emotions  the  cognitive  element 
tends  to  become  prominent.  So  far  as  the  emotional  content 
is  concerned,  sentiments  are  associated  with  sensation  com- 
plexes affecting  the  brain.  They  are  classified  as  (1)  Moral, 
(2)  Intellectual,  and  (3)  aesthetic. 

Moral  Sentiments  involve  the  sense  of  duty  or  con- 
science, in  its  social  and  religious  aspects  and  relate  to  the 
different  virtues,  which  strictly  belong  to  the  study  of  Ethics. 
Morality  results  from  the  normal  development  of  altruism,  and 
has  been  defined  by  Mercier  as  the  ability  to  forego  immediate 
pleasure  for  future  benefit.  Thus  immediate  pleasure  may 
be  a  fleeting  self-indulgence,  possibly  harmful  to  the  individual 
or  to  others,  whilst  the  ulterior  benefit  obtained  by  abstainmg 
from  self-indulgence  may  be  lasting  and  of  incalculable  good 
in  the  future.  Morality  is  a  matter  of  education  in  controlling 
the  lower  instincts.  The  moral  code  applies  to  communities 
as  well  as  to  individuals ;  it  is  at  the  foundation  of  sound 
government,  and  to  some  extent  embraces  the  sciences  of 
Jurisprudence,  Sociology  and  Theology. 

Intellectual  Sentiments  result  from  the  higher  emotions 
brought  into  action  in  establishing  the  Truth  or  Belief  of  any 
given  statement,  which  is  beyond  the  person's  contradiction 
or  doubt,  or  in  arriving  at  the  Justice  of  any  course  of  action. 
Li  determining  the  truth  of  any  proposition,  or  the  justice  of 
an  action,  the  logical  mind  weighs  the  evidence  given  by  the 
senses  and  dehberates  thereon  with  as  little  feehng  as  possible. 
The  essentially  feminine  mind  is  largely  guided  to  a  conclusion 
by  feeling,  whilst  the  child's  receptive  mind  forms  but  feeble 
associations,  and  imphcitl}^  believes  whatever  is  suggested  to 
it.     In  persons  with  general  instability  of  ideas  and  feehngs, 


FEELING,   EMOTION,   AND   SENTIMENT  53 

the  antithesis  of  belief  results,  namely  Doubt,  which  leads  to 
hesitancy  of  action  or  inaction. 

jEsthetic  Sentiments  are  those  higher  emotions  on  which 
artistic  tastes  and  recreations  depend,  man}-  of  which  involve 
the  exercise  of  imagination  in  a  high  degree,  viz.  painting,  archi- 
tecture, music,  poetr}^,  drama,  the  sense  of  humour,  beauty, 
etc.  These  are  all  natural  endowments  caj^able  of  further 
development,  and  which  in  varjdng  degrees  enrich  the  equip- 
ment of  a  highly  organised  mental  constitution. 

Physical  Basis  of  Sentiments. — Sentiments  being  intel- 
lectualised  emotions,  the  nervous  substrata  underljdng  the 
ideational  processes  are  involved,  as  well  as  the  emotional 
mechanism  already  described.  In  the  association  area  of 
the  Pre-Erontal  lobe  where  ideas  with  their  subjacent  emo- 
tional tone  are  translated  into  the  springs  for  action,  it 
may  be  surmised  that  the  chief  basis  for  the  moral  and  other 
sentiments  exists. 

Disorders  of  Sentiments. — Here  also  there  may  be  (1) 
Excess,  (2)  Deficiency,  or  (3)  Perversion.  Excess  is  exhibited 
in  some  ill-balanced  persons  who  are  hyper-conscientious  and 
are  always  weighing  motives,  and  who  doubt  the  moralit}'  of 
their  words  and  actions.  Those  with  a  pronounced  aesthetic 
sentiment  are  not  infrequently  wanting  in  the  moral  senti- 
ment, and  are  also  prone  to  be  mentally  unstable.  Thus 
there  is  amongst  the  class  of  artists,  poets,  and  musicians, 
whose  trend  has  been  abnormally  confined  to  the  aesthetic 
sphere,  a  tendency  to  certain  actions  that  has  caused  various 
authors  to  place  some  of  them  within  the  category  of  the 
moral  degenerates,  although  their  reasoning  powers  may  be 
unimpaired. 

Li  insanity  and  mental  dissolution  in  general,  the  aesthetic 
qualities  being  the  latest  to  be  acquired  in  the  education  of  the 
individual,  are  generally  the  first  to  become  disordered,  and  in- 
deed to  become  grotesque,  as  exhibited  by  the  works  of  art 
emanating  from  insane  patients.  The  lack  of  moral  sentiment 
is  instanced  hy  the  immoral  conduct,  untruthfuhiess,  and 
vicious  tendencies  observed  in  particular  in  some  Alcoholics, 
General  Paralytics,  and  sometimes  in  cases  of  Senihty  and 
Imbecility.  Even  in  the  milder  types  of  Mania  and  Melan- 
cholia there  is  something  wantmg  in  manners  and  courtesyj 


54  MENTAL   DISEASES 

and  patients  are  defective   in   normal   social  and  recreative 
activities,  betokening  a  disordered  aesthetic  sentiment. 

The  moral  sentiment  of  the  criminal  is  perverted  to  suit 
his  own  ends,  and  is  not  the  result  of  disease.  Unlike  an 
insane  person,  he  can  restrain  himself  from  evil,  if  he  wishes ; 
he  voluntarily  takes  the  risks  of  the  life  he  leads,  and  the  conse- 
quences it  entails.  Some  criminals,  however,  not  being  actually 
insane,  are  weak-minded  and  are  scarcely  fully  responsible. 
These  are  congenitally  deficient  as  regards  the  moral  sense,  and 
require  permanent  segregation  rather  than  punishment. 


CHAPTER   V 

INSTINCT,    VOLITION,    AND    ATTENTION 
(CONATION) 

Conduct  consists  of  purposive  action  which  is  both  In- 
stinctive and  Vohtional.  By  this  means  a  hving  being 
maintains  his  relations  with  his  surroundings  and  with  other 
living  beings.  It  is  composed  of  the  various  activities  by  which 
the  adjustment  or  adaptation  of  the  human  organism  to  the 
environment  is  effected.  All  life  may  be  regarded  as  a  re- 
action between  an  organism  and  its  surrounding  medium. 
From  its  medium  the  organism  derives  what  it  requires,  so  as 
to  increase  and  multiply  until  its  potentiality  is  exhausted  and 
it  languishes  and  perishes. 

By  the  action  or  conduct  of  a  person  is  his  sanity  or  in- 
sanity largely  determined  in  the  legal  and  practical  sense,  even 
if  not  in  the  medical  and  scientific  discernment  of  soundness 
or  unsoundness  of  mind.  From  the  physical  standpoint,  a 
man's  conduct  must  be  said  to  be  dependent  on  his  inherited 
nervous  disposition  or  what  has  been  handed  down  to  him  by 
his  ancestors  (Nature),  and  on  his  acquired  nervous  mechanism 
due  to  his  training  and  education  (Nurture).  Besides  the 
conduct  of  the  person  moving  in  any  particular  social  medium, 
his  speech  and  what  he  writes  must  be  taken  into  account. 
Language  consists  of  motor  reaction  of  the  highest  order,  and 
is  significant  of  the  mental  state  of  the  person  and  of  what  his 
outward  action  towards  others  is  likely  to  be.  Language,  indeed, 
may  be  considered  as  conduct  on  a  high  plane.  The  lower 
animals  react  on  one  another  by  means  of  gestures  and  noises 
which  may  be  regarded  as  a  primitive  form  of  language.  In 
the  human  species  communication  between  mankind  is  carried 
on  by  means  of  articulate  and  written  speech,  the  symbols 
for  which  differ  in  various  countries. 

55 


56  MENTAL   DISEASES 

Human  action  or  conduct  is  for  the  most  part  based  on 
reflexes  and  instincts  which  have  been  trained  and  modified 
by  the  education  of  the  association  areas  in  the  cortex  cerebri, 
or  in  other  words,  which  have  been  moulded  by  voHtion. 
Such  action,  indeed,  when  directed  into  the  best  channels, 
is  the  very  essence  of  what  is  termed  "  Character."  This  it  is 
which  counts  for  much  in  gaining  the  prizes  in  life,  far  out- 
weighing the  cognitive  acquisitions  of  the  individual. 

Reaction  Time. — Experiments  in  cerebration  have  been 
devised  hj  Mimsterberg  and  others  for  testing  the  time  between 
the  apphcation  of  a  stimulus  and  its  motor  response  in  different 
persons,  and  for  estimating  the  time  taken  in  appreciating 
a  sensation  or  in  exhibiting  a  choice.  Reaction  time  is  in- 
variably dela^^ed  in  states  of  depression,  and  is  generalh^ 
accelerated  in  Mania. 

Reaction  time  has  latterly  been  further  apphed  in  ps3xho- 
analysis,  by  giving  seriatim  a  number  of  stimulus  words  and 
asking  a  patient  after  each  word  to  give  an  associated  word  of 
response.  By  the  nature  of  the  latter,  coupled  with  an}'  undue 
delay  in  reaction  time,  an  emotional  line  of  thought  or  buried 
complex  of  ideas  is  sometimes  elucidated. 

Human  action  may  be  classified  as  (1)  Reflex,  (2)  In- 
stinctive, and  (3)  Volitional  or  Voluntary.  Derived  from 
Volitional  action  is  that  which  is  (4)  Impulsive,  (5)  Habitual, 
and  (6)  Automatic. 

Beflex  Action. — All  action  is  m  the  end  derived  from  the 
primal  reflex  to  which  all  organisms  are  subject,  ^dz.  a  reaction 
to  a  stimulus.  Such  reflex  action  occurs  even  in  the  highest 
levels,  e.  g.  when  a  man  receives  a  blow  from  an  opponent 
and  at  once  responds  with  a  counter-blow.  Reflex  action 
is,  however,  best  typified  in  the  lower  levels,  which  have  no  con- 
comitant psychic  equivalents,  such  as  the  plantar  reflex,  which 
may  be  regarded  as  a  remnant  of  the  different  congenital 
mechanisms  to  prevent  self -injury,  e.  g.  blinking  of  the  eyes,  etc. 

The  physical  basis  of  reflex  action  the  student  i^dll  have 
learnt  from  his  preliminary  studies  in  physiology;  the  reflex 
disorders  being  due  to  interference  with,  the  individual  arcs 
involved,  or  with  the  controlling  mechanism  of  higher  nervous 
functions. 

Instinctive  Action  is   a   grade  higher  than   reflex   action, 


INSTINCT,   VOLITION,   AND   ATTENTION         57 

and  its  nature  is  more  complex,  and  it  has,  moreover,  a 
psychic  accompaniment.  It  is  also  due  to  a  congenital 
nervous  disposition,  for  its  organisation  dates  almost  from 
birth,  and  therefore  follows  closely  on  reflex  action. 

Instinct  is  purposive  action  in  pursuit  of  ends  mthout 
foresight  or  education.  Instincts  are  psychic  in  so  far  as  they 
are  connected  with  the  corresponding  emotions,  and  indeed  they 
possess  the  same  mechanism  ;  they  may  be  said  to  be  the  motor 
expression  of  the  emotions.  When  certain  emotions  are 
intensified,  the  subjective  or  passive  state  may  be  described  as 
one  of  Desire.  Such  instincts  or  desires  include  the  various 
appetites  and  propensities,  and  consist  of  the  essential  strivings, 
impulses,  or  motives  to  action.  These  constitute  the  innate 
conative  tendencies  of  the  mind.  Congenital  and  therefore 
involuntary  in  origin,  yet,  under  healthy  training  in  the  human 
species,  they  may  be  brought  under  the  control  of  the  Will  as 
development  proceeds,  in  accordance  with  the  plastic  nature 
of  the  supreme  nerve  centres.  In  the  lower  animals  the 
higher  brain  areas  contain  perceptual  rather  than  ideational 
areas,  and  instincts  reign  supreme ;  indeed,  the  whole  life  of 
most  animals  is  largely  composed  of  a  blind  obedience  to  their 
organised  nervous  mechanism ;  many  animals,  however,  also 
learn  from  experience  and  display  intelligence. 

There  are  two  fundamental  desires  or  instincts  from  which 
all  others  are  derived,  viz.  (1)  the  Desire  to  Live,  and  (2)  the 
Desire  to  Reproduce.  Of  these  two  instincts  it  is  doubtful 
which  should  be  given  priority.  From  Nature's  point  of  view 
the  organism  is  preserved  solely  for  the  purpose  that  it  may 
be  perpetuated. 

From  (1)  the  Desire  to  Live,  or  the  Love  of  Life  and  the  Fear 
of  Death,  are  developed  the  self -conservative  or  egoistic  activi- 
ties, viz.  the  appetites  for  food  and  drink  to  maintain  the  body  in 
a  healthy  state  of  nutrition  ;  the  necessity  of  earning  a  living ; 
the  desire  for  exercise,  and  the  display  of  energy ;  the  avoidance 
of  dangers,  including  the  necessity  of  cleanliness  and  hygiene. 

From  (2)  the  Desire  for  Reproduction  are  developed  the 
altruistic  activities.  The  sexual  instinct  in  its  highest  refine- 
ment is  crj^stallised  into  the  passion  of  Love ;  derived  from  it 
are  the  duties  of  parentage  and  the  affection  for  the  offspring, 
with  the  tenderness  and  care  for  the  poor  and  helple&s  in  generaL 


58  MENTAL   DISEASES 

From  it  arises  also  the  social  instinct,  which  is  founded  on  family 
life,  and  develops  as  an  individual  finds  he  can  thrive  better 
in  a  community  of  his  fellow  men  than  when  he  is  alone.  It  is 
at  the  basis  of  sympathy  for  others,  and  is  the  foundation  of 
ethics  and  morals  as  well  as  of  patriotism  and  religion.  Freud 
in  particular  has  enlarged  our  ideas  on  the  wide  area  of  activities 
fundamentally  dependent  on  the  sexual  instinct. 

In  the  growth  of  a  child  from  infancy  upwards  it  is  of 
interest  to  watch  the  development  of  movements  and  instincts 
as  organisation  proceeds.  This  has  been  particularly  investi- 
gated by  Preyer.  At  first  all  movements  are  microkinetic 
and  purposeless.  Muscular  contractions  take  place  irregularly 
as  an  outlet  for  energy.  Ordinary  reflexes  are  practically 
absent  during  the  first  few  days  of  life,  except  that  of  sucking  ; 
and  nothing  but  the  most  primitive  feeling  probably  exists, 
although  reactions  to  light,  sound,  and  touch  stimuli  are 
manifest  from  birth,  and  those  to  taste  and  smell  follow  soon 
after.  The  infant  sleeps  nearly  twenty  out  of  the  twenty- 
four  hours  and  spends  the  rest  of  its  time  feeding,  or  crjdng  to 
be  nursed. 

At  the  fourth  week  the  child  smiles,  and  the  eyeballs  follow 
a  lighted  candle.  At  the  ninth  week  perception  is  being 
established  and  objects  are  cognised  and  recognised.  At 
three  months  purposeful  movements  are  executed  owing  to  the 
myelinisation  of  the  pyramidal  tract,  which  process  is  complete 
at  the  seventeenth  month.  At  four  months  the  nervous 
mechanism  controlling  the  spinal  muscles  develops,  so  that  the 
child  begins  to  make  attempts  to  sit  up  and  it  grasps  at  objects 
with  the  instinct  to  place  them  in  its  mouth.  At  six  months 
the  child's  perceptive  experience  has  taught  it  some  notion 
of  space  and  distance  and  the  faculty  of  imitation  proceeds. 
At  ten  months  the  child  learns  to  crawl  on  its  arms  and  legs, 
it  imitates  words  and  accepts  suggestions.  At  about  a  year 
the  child  co-ordinates  its  muscles  so  as  to  gain  its  equilibrium 
to  stand  erect,  and  then  begins  to  walk.  At  a  year  and  a 
quarter  the  child  begins  to  talk  and  shows  indications  of 
developing  Will.  At  a  year  and  three  quarters  curiosity  and 
acquisitiveness  are  exhibited ;  the  instinct  of  cleanliness 
manifests  itself  and  the  child  should  cease  to  be  wet  and  dirty. 
Ideas  of  time  follow.     At  the  seventh  year,  if  not  before,  con- 


INSTINCT,   VOLITION,   AND   ATTENTION  59 

struct! veness  takes  the  place  of  destructiveness.  At  puberty 
the  secondary  sexual  characteristics  develop,  mth  ideas  of 
modesty  and  shame,  and  jealousy  supervenes  later. 

During  adolescence  the  ideational  centres  receive  fresh 
impetus  from  educational  training  and  the  storage  of  experi- 
ence, and  the  desire  to  energise  is  sho^\al  in  interest  for  sports 
and  pastimes.  The  young  man  seeks  to  earn  his  living,  the 
girl  develops  into  womanhood,  and  matrimonial  unions 
ensue . 

Physical  Basis  of  Instincts. — This  has  the  same  nervous 
mechanism  as  is  the  case  with  emotions.  In  emotions,  how- 
ever, the  expenditure  of  energ}^  is  subjective  in  the  domain  of 
feeling,  and  the  expression  thereof  or  motor  element  is  to  a 
great  extent  abortive  or  repressed;  Avhereas  in  instincts,  the 
nervous  currents  for  the  most  part  are  directed  into  motor  tracts. 
An  external  perception  or  subjective  idea  distributes  currents 
of  energy  from  the  association  areas  to  the  congenital  nervous 
tracts  for  the  execution  of  the  different  instinctive  movements, 
which  are  accompanied  by  more  or  less  feeling.  Instincts 
are  the  springs  or  groundwork  of  all  conduct,  but  are  subject 
to  the  correction  and  restrainmg  influence  of  Will  through 
currents  passing  from  the  cortex  do^v^l  the  pyramidal  tract. 

Disorders  of  Instincts. — Instincts  may  be  (1)  Exalted, 
(2)  Deficient,  or  (3)  Perverted.  They  are  for  the  most  part 
exalted  in  Mania,  General  Paralysis,  Epilepsy,  Paranoia,  and 
Alcoholic  insanity;  patients  desire  to  energise  too  much  and 
are  morbidly  restless,  sometimes  they  eat  enormousl}^ ;  the 
sexual  instinct  in  particular  tends  to  become  uncontrolled. 

They  are  deficient  in  Melancholia,  Dementia,  and  Amentia, 
e.  g.  aversion  from  food,  laziness  and  lassitude,  unwillingness  to 
take  part  in  recreations,  incapacity  to  earn  a  living. 

They  are  perverted  in  many  mental  disorders.  Amongst 
these  perversions  are  apathy  or  hatred  towards  relatives, 
e.  g.  the  puerperal  woman  frequently  takes  a  violent  dislike  to 
her  husband  and  child.  Here  may  be  included  also  many  evil 
practices  mentioned  under  bad  habits.  Special  notice  must 
be  given  to  perversion  of  the  two  primary  instincts  of  self- 
preservation  and  reproduction. 

Perversion  of  the  Desire  to  Live  occurs  as  Suicide  and  in 
its  minor  degree  as  Refusal  of  Food. 


60  MENTAL   DISEASES 

Suicide. — This  is  a  common  s^Tnptom  in  Melancholia  and 
occurs  also  in  Alcoholism,  Epilepsy,  Psychasthenia,  and  other 
conditions.  It  may  be  due  to  worry  and  insomnia,  or  be  the 
result  of  delusions — that  a  patient  is  unfit  to  live,  that  he  is 
ruined  financially  or  morall}",  that  he  is  contaminating  others ; 
or  it  occurs  to  avoid  imaginary  persecution,  to  escape  illness 
real  or  imaginary,  to  save  trouble  or  expense,  or  from  a 
general  state  of  misery.  It  ma}'^  be  impulsive,  premeditative, 
or  it  may  result  from  confusion ;  an  unsuccessful  attempt 
sometimes  leading  to  the  patient's  recovery.  It  may  also 
occur  from  auditory  hallucinations  commanding  a  patient 
to  commit  the  act.  In  Delirium,  Mania,  and  General  Paralj^sis 
it  occasionally  happens  by  accident.  Suicide  is  not  confined 
to  insanity  and  it  may  be  committed  to  benefit  others.  It  is 
more  frequent  in  some  nationalities  than  in  others,  and  its 
incidence  is  higher  in  the  spring  and  summer  months. 

Refusal  of  Food. — This  occurs  m  Melancholia  in  most 
cases,  but  also  in  Mania,  General  Parah^sis  and  other  conditions. 
It  is  more  common  in  private  than  in  pauper  patients.  It 
may  be  due  to  delusions  and  hallucinations,  the  patient 
believing  that  the  food  is  poisoned,  that  it  tastes  or  smells  bad, 
that  solids  and  liquids  decompose  ^^dthin  him,  that  he  feels  too 
wretched  to  eat,  that  he  is  commanded  not  to  eat,  that  he 
cannot  swallow,  that  he  is  blocked  up,  that  he  desires  to  give 
trouble,  or  that  he  wishes  to  die. 

Perversion  of  the  Sexual  Instinct  may  arise  from  absence  of 
desire,  or  from  excessive  desire  accompanied  by  malpractices ; 
or  desire  may  be  dormant  and  be  aroused  only  by  abnormal 
means  such  as  a  scent  or  fetish  of  some  kind,  or  b}"  flagellation, 
active  or  passive.  It  occurs  also  as  Masturbation  and  Sexual 
Inversion. 

Masturbation. — This  is  in  great  measure  due  to  bad  ex- 
ample in  youth.  It  is  more  frequent  in  the  male  sex,  and  is 
to  some  extent  an  index  of  nervous  mstabilit}",  and  occurs 
even  in  young  children.  It  is  common  in  acute  insanity, 
especially  in  adolescent  cases,  and  also  in  some  degenerates. 
To  a  special  class  of  the  latter  belong  those  Avho  practise  the 
vice  before  religious  shrines,  or  as  "  exhibitionists,"  and  are 
amenable  to  the  law  for  public  indecency. 

Sexual  Inversion. — In  this  anomaly  desire  is  towards  the 


INSTINCT,   VOLITION,   AND   ATTENTION        61 

same  sex  (homo-sexuality),  and  may  be  active  or  passive.  It 
is  probabl}''  not  more  common  in  the  insane  than  in  the  sane, 
but  occurs  in  some  Degenerates,  male  and  female,  and  is  some- 
times associated  mth  Paranoia .  Its  practice  renders  the  parties 
subject  to  the  criminal  law. 

Will.  Volition  {or  Voluntary  Action). — An  act  of  Will 
fmally  determines  the  conduct  of  a  normal  indi\adual.  This 
"  fiat  "  of  the  "vvill  may  be  said  to  exist  in  all  creatures  having 
a  certain  development  of  the  association  areas  of  the  cortex 
cerebri,  such  as  exists  in  Mammalia,  and  m  the  highest  degree 
in  the  human  species .  Deliberation  as  a  result  of  the  association 
of  ideas  comes  into  play,  the  emotions  and  instinctive  tend- 
encies produce  their  quota,  resulting  in  what  is  called  a  choice 
in  the  conflict  of  motives.  This  choice  is  guided  in  the  long 
run  by  feelings  of  pleasure  or  pain,  until  finally  the  idea  of 
a  purposive  act  leads  to  its  "intention"  and  results  in  its 
performance.  A  volition  or  voluntary  act  is  in  reality  a 
reinforced  ideomotor  act.  It  tends  to  be  facilitated  by 
repetition  as  do  other  mental  processes,  although  at  first  it 
demands  attention  and  involves  efi^ort  (conation).  The  Will 
of  a  fully  developed  healthy  man  may  be  considered  that  force 
in  Nature  in  which  Consciousness  reaches  its  acme. 

Upon  the  complexity  of  the  association  of  ideas,  dependent 
on  the  cerebral  cortex  with  which  the  individual  has  been 
endowed,  and  upon  the  education  and  experience  to  which  he  has 
been  subjected,  does  the  nature  of  his  act  of  Will  turn.  On  the 
stability  of  his  judgment  rests  the  strength  of  his  -v^dll-power, 
and  his  resulting  actions.  To  the  individual  experiencing 
a  conflict  of  motives,  as  well  as  to  others  who  bear  witness 
to  his  actions  or  intentions,  his  Will  is  free.  A  man  says  he 
has  choice  to  move  to  the  right  or  to  the  left,  as  he  wishes  or 
wills,  and  his  muscles  perform  a  voluntary  act.  Without 
entering  into  the  obscure  region  of  Metaph3'sics  the  student 
may  take  it  for  granted  that  such  so-called  freedom  is  governed 
by  the  organisation  of  his  complex  mental  processes  which 
ultimately  determines  his  conduct.  The  closer  a  man"s 
character  is  known  the  more  certainly  can  his  actions  be  pre- 
dicted in  any  possible  course  of  conduct.  Punishment  for 
actions  committed  against  the  public  weal  must,  however, 
rightly   be    visited    upon    the    law-breaker,    seeing    that    his 


62  MENTAL   DISEASES 

mal-organisation  lias  largely  proceeded  from  failure  to  stimu- 
late his  higher  nature,  and  neglect  of  those  duties  in  life  that 
conduce  to  his  best  development  and  the  welfare  of  others. 

Will  is  spoken  of  as  inhibiting  or  controlling  the  instincts 
of  mankind  or  those  desires  which  mainly  actuate  conduct. 
Will  can  hardly  be  said  to  exist  before  the  age  of  fifteen 
months  ;  it  grows  year  by  year  pari  passu  with  mental  develop- 
ment, and  fails  as  old  age  approaches. 

Impulsive  Action,  commonly  called  an  impulse,  is  an  action 
short  of  full  deliberation  and  control.  This  occurs  in  children 
and  young  people  with  immature  will-power,  and  in  mental 
disorders  where  inhibition  is  markedly  wanting. 

Habitual  Action,  or  a  habit,  is  voluntary  action  which 
from  repetition  and  facilitation  is  almost  becoming  automatic, 
e.  g.  early  rising,  punctuality,  etc.  Habits  are  conscious 
actions  and  may  be  good  or  bad,  the  latter  playing  no  small 
part  in  mental  disorders. 

Automatic  Action  is  that  which  was  at  one  time  voluntary, 
and  from  constant  repetition  by  training  and  education  has 
become  organised,  and  therefore  scarcely  affects  conscious- 
ness, e.  g.  walking,  piano-playing,  and  other  dexterities. 

Physical  Basis  of  Will. — The  association  area  of  the  Pre- 
Frontal  lobes  is  regarded  as  the  material  substratum  for  the 
ideomotor  centres,  and  here  probably  also  nervous  energy  is 
concentrated  for  the  still  higher  operations  of  Will.  The 
ideomotor  centres  may  be  considered  as  being  informed  by 
impressions  or  images  received  through  fibres  of  the  associ- 
ation neurons  from  the  kinsesthetic  centres  in  the  sensory 
area  of  the  parietal  lobe,  rather  than  by  reversed  currents 
from  the  motor  area,  producing  the  so-called  sense  of  motor 
innervation. 

The  springs  for  Volition  may  be  said  to  arise  from  all  parts 
of  the  cortex,  but  in  right-handed  people  it  has  been  suggested 
that  the  left  pre-frontal  lobe  has  the  pre-eminence  in  co- 
ordinating voluntary  movements,  and  probably  those  that  are 
impulsive  also ;  whilst  habitual  and  automatic  actions  may 
possibly  be  relegated  to  activity  in  the  right  pre-frontal  lobe. 
In  the  latter  the  synaptic  resistance  between  the  neurons  has 
been  overcome  by  constant  repetition,  but  in  voluntary  acts 
the  synapses  still  exert  their  full  influence  and  give  rise  to  the 


INSTINCT,   VOLITION,   AND  ATTENTION        63 

feeling  of  effort  and  inhibition ;  impulsive  acts  may  be  regarded 
as  those  which  are  wanting  in  full  volition. 

The  pre-frontal  lobe,  by  means  of  association  fibres,  receives 
afferent  impressions  through  the  other  association  areas 
from  the  perception  and  ideational  centres ;  it  sends  efferent 
impulses  through  the  motor  area  and  efferent  projection 
system  to  the  pyramidal  tract  and  bodily  musculature  for  the 
execution  of  voluntary  movements ;  it  thereby  drains  away 
nervous  energy  from  the  instinctive  mechanism. 

The  motor  area  (Fig.  15)  may  be  regarded  as  consisting 
of  two  parts,  viz.  (1)  the  ascending  frontal  or  pre-central 
convolution  for  the  primary  muscular  movements,  and  (2)  the 
posterior  part  of  the  first,  second  and  third  frontal  convolutions 
which  subserve  higher  muscular  mechanisms  (dexterities), 
including  the  motor  mechanism  for  speech  and  that  for  writ- 
ing ;  both  of  wliich  are  in  commissural  connexion  with  the 
sensory  or  kinsesthetic  area  in  the  parietal  lobe,  and  with  the 
auditory  and  visual  perception  areas  as  the  diagram  overleaf 
(Fig.  17)  illustrates. 

Disorders  of  Volition. — The  will-power  may  be  (1)  Ex- 
cessive, (2)  Deficient,  or  (3)  Perverted.  Excess  of  will-power 
can  rarely  be  regarded  as  abnormal,  but  the  condition  called 
Hyperbulia  does  occur  in  the  obstinacy  and  persistence  of 
many  delusional  cases,  in  some  imbeciles,  and  in  self-willed 
children.  Defective  volition  is  a  common  feature  in  mental 
maladies,  the  association  of  ideas  may  be  unaccompanied  by 
proper  feeling,  and  the  patient  experiences  an  equahty  of 
motives  which  paralj^ses  liis  actions.  Such  weakness  of  will, 
or  failure  in  impulsion,  is  designated  Abulia,  and  is  particularly 
marked  in  Psychasthenia,  leading  to  inaction  or  to  acts  of  in- 
decision and  doubt.  Li  obsessional  cases,  phrases  are  apt  to 
recur,  and  obscene  expressions  may  be  uttered  (Coprolaha),  the 
patient  being  the  victim  of  imperative  ideas  and  phobias. 
These  continually  obtrude  from  the  weight  of  emotional  stress, 
which  produces  complexes  that  are  beyond  the  control  of  the 
Will  and  may  lead  to  impulses .  In  Stupor  and  Dementia  the  mil- 
power  may  be  stated  to  be  wanting,  and  in  "  Automatism  " 
from  Epilepsy,  Hypnotism,  or  Somnambulism,  it  is  entirety 
absent.  In  intermediate  conditions,  such  as  mild  degrees  of 
Dementia  and  in  General  Paralysis,  the  will-power  is  Facile, 


64 


MENTAL  DISEASES 


the  patient  responding  as  a  rule  easil}^  to  suggestions.  Per- 
version of  Volition  shows  itself  in  morbid  actions,  impulses, 
and  habits,  resulting  from  delusions  and  hallucinations  or 
from  excessive  emotion  in  acute  insanity.  Impulsive  actions 
occur  sometimes  of  an  objectionable  or  even  dangerous 
character,  in  Epilepsy  and  other  mental  disorders,  such  as 
indecent  exposure,  or  sexual  \ace,  impulses  to  strike,  to  steal, 
to  burn,  to  drink,  to  commit  suicide  or  homicide.     Suicide  has 


Fig.   17. — The  language  mechanism — speech  and  writing. 


already  been  referred  to  as  a  perversion  of  instinct.  It  is  some- 
times associated  with  homicide  wliich  ma}'  be  either  impulsive  or 
premeditated,  and  is  frequently  due  to  "voices  "  or  delusions, 
the  latter  being  at  times  concealed  hj  the  patient  till  the  act 
has  been  performed.  Of  less  import  as  regards  others,  but 
impljdng  serious  mental  reduction  are  those  insane  habits — 
stereotj'ped  movements,  mannerisms,  and  negativism — which 
occur  in  Dementia  Praecox  and  have  become  automatic  and 
are  incapable  of  correction  by  the  patient.  Similarly-  must  be 
mentioned  the  bad  habits  which  occur  in  many  forms  of  in- 
sanity, and  especially  in  chronic  Mania  and  Dementia,  such  as 


INSTINCT,   VOLITION,   AND   ATTENTION         65 

wet  and  dirt}^  habits,  destructiveness,  noisiness,  fidgetiness, 
folie  du  toucher,  carelessness  in  dress,  removal  of  clothing, 
eating  filth,  the  collection  of  rubbish,  etc.  Nervousness  shows 
itself  even  in  the  sane  individual  by  a  general  restlessness, 
the  biting  of  nails,  etc.  The  terms  apraxia  and  dyspraxia  are 
applied  to  the  inability  of,  or  difficulty  in,  carrying  out 
movements  from  pre-frontal  dissolution,  as  in  Senility,  Alco- 
holic and  other  conditions,  owing  to  the  loss  of  memory  of 
motor  ideas.  It  may  also  be  due  to  imperception  (sensory 
apraxia,  vide  p.  36).  Thus  a  patient  may  not  know  what 
a  pen  is  for,  whilst  in  motor  apraxia  he  has  lost  his  ideas 
for  the  requisite  movements  to  write  or  to  speak.  EcJio- 
praxia  is  the  imitation  of  the  movements  of  others.  The  ideo- 
motor  centres  are  also  occasionally  disordered,  so  as  to  give 
rise  to  psychomotor  hallucinations  or  imaginary  movements. 

Lastly,  Volitional  action  is  necessarily  to  some  extent 
interfered  with  by  any  lesion  of  the  efferent  or  motor  tract,  as 
in  hemiplegia.  Right  hemiplegia  is  invariably  accompanied 
by  motor  aphasia  and  agraphia,  from  affection  of  Broca's 
convolution  and  the  writing  centre  respectively,  or  as  Marie 
has  suggested,  from  subcortical  injury. 

Disorders  of  Speech  are  exhibited  by  incoherence,  con- 
fusion, mere  rambling  (mental  wandering),  or  by  too  rapid  or 
too  slow  association  of  ideas.  Mutism  results  from  absence  of 
ideas,  or  more  generally  from  delusions,  or  from  congenital  deaf- 
ness. Hesitancy  of  speech  and  clipping  of  words  are  witnessed 
in  General  Paralysis  and  Alcoholic  Psychoses ;  and  Aphasia 
occurs  in  these  conditions  and  also  in  Senile  Insanity.  Verbiger- 
ation and  Echolalia  have  been  already  mentioned  (vide  p.  43). 
Stammering  and  stuttering  are  less  common  in  the  insane 
than  in  the  neurotic  stocks  whence  they  spring. 

Disorders  of  Handwriting  are  well  demonstrated  in 
General  Paralysis,  letters  and  words  being  wrongly  inserted 
or  left  out,  tremor  is  shown,  and  the  calligraphy  is  altered  in 
size.  Excited  General  Paralytics  in  the  early  stage  write 
much,  as  do  also  Paranoiacs,  the  latter  sometimes  using  codes 
and  illustrations  to  explain  their  delusions.  The  writing  of 
patients  suffering  from  Dementia  Prsecox  betrays  the  charac- 
teristics of  that  disorder.  Prequently  Melancholiacs  write  with 
small  letters  and  Maniacs  with  large  letters. 


First  stage  of  general  paralysis. 


^^^-r^^  ^^^^^_^ 


Second  stage  of  general  paralysis. 
Paranoia. 

Dementia  Prsecox. 
C/'     ^  ^  SZIA  .Wv.^  ^^-^  ^7Z>nJ^€^ 


Dementia  Prsecox. 

.U^  A  ^--^         —  "^         '" 

Melancholia. 


"t^^^^A^ 


^^^-LJL      rc^-utyC^ 


Mania. 

Fig.    18. — Handwriting  in  the  insane. 

()G 


INSTINCT,   VOLITION,   AND    ATTENTION  67 

Attention  is  the  process  by  which  an  individual  is  able  to 
concentrate  his  mental  energy  in  a  specific  direction. 

In  order  to  perceive  clearly,  the  body  must  be  posed  for 
the  reception  of  stimuli  from  the  objects  perceived.  A  state 
of  Apperception  (vide  p.  35)  is  reached  with  regard  to  a  central 
object,  and  its  surroundings  merge  into  the  fringe  of  the  field 
of  Consciousness.  In  ideation  also,  the  association  of  ideas  is, 
or  ought  to  be,  under  the  control  of  the  act  of  attention. 
Without  attention  there  would  be  no  concentration  for  co- 
ordinate action.  In  order  to  think  clearly  the  stream  of  mental 
energy  is  directed  to  a  circumscribed  association  tract,  and 
external  stimuli  are  passed  unheeded.  The  ability  to  learn 
from  a  book  or  from  a  lecturer  likewise  means  mental  con- 
centration on  what  is  read  or  heard,  and  is  largely  developed 
by  habit.  Abstract  ideas  involve  closer  attention  than  is 
necessary  for  concrete  object  lessons.  Thus  is  explained  the 
utility  of  practical  demonstrations,  and  indeed  that  of  the  whole 
kindergarten  system  of  teaching  for  children. 

Laws  of  attention  have  been  formulated  with  regard  to 
the  number  of  objects  that  can  be  attended  to  (up  to  five  or 
six),  the  degree  of  attention,  its  fluctuation  from  a  condition  of 
inertia  to  a  state  of  tension,  its  effect  on  the  intensity  and 
duration  of  sensations,  and  its  relation  to  fatigue. 

Varieties  of  Attention.- — Attention  may  be  (1)  Active,  or 
voluntary,  which  demands  effort,  or  what  is  generally  known  as 
Conation  (conor,  "  I  strive  '").  It  develops  gradually  during 
the  education  of  the  child  and  does  not  reach  its  full  power 
until  maturity,  when  Will  and  self-control  are  fully  developed. 

(2)  Passive,  or  what  is  called  reflex  and  instinctive,  which 
is  dependent  on  what  interests  the  person  and  is  due  to  both 
congenital  and  acquired  dispositions.  This  condition  is 
involuntary  and  is  without  any  feeling  of  strife  or  sense  of 
effort.  It  also  exists  secondary  to  attention  that  was  at  one 
time  active  and  by  constant  repetition  has  become  automatic. 

Physical  Basis  of  Attention. — As  the  word — Attention — 
implies,  a  state  of  tension  of  certain  parts  is  usually  in  process, 
which  results  in  fatigue  unless  relaxation  follows.  In  passive 
attention,  however,  the  nerve  currents  are  on  an  organised 
lower  level  and  easily  set  the  muscular  mechanism  in  action. 
In  active  attention  the  perception  or  idea  is  accompanied  by 


68  MENTAL   DISEASES 

a  drainage  of  nervous  energ}'  from  other  cortical  centres,  wliicli 
energy  is  concentrated  into  the  highest  association  areas  in 
the  pre-frontal  lobe,  mostly  of  the  left  cerebral  hemisphere. 
The  currents  pass  through  the  motor  area  and  pyramidal 
tract  to  the  musculature  in  general,  and  especially  to  the 
muscles  of  the  head  and  neck,  the  ej^eballs  and  face.  This 
produces  what  is  called  the  muscular  element  of  thought  of 
Bevan  Lewis ;  and  it  is  probable  that  a  tendenc}^  to  abortive 
contraction  of  the  speech  muscles  takes  place  during  the  process 
of  concentrated  thought. 

Disorders  of  Attention. — These  are  (1)  Excess  of  the 
passive  form  and  (2)  Defect  of  voluntary  attention.  As  passive 
or  instinctive  attention  is  increased  {hyper -attention)  in  cases  of 
Mania,  so  in  that  disorder  is  active  or  voluntarj^  attention 
weakened  {inattention  or  distraction).  These  processes  also  occur 
in  Acute  Melancholia,  Confusional  insanit}",  and  Congenital 
states.  Li  Chronic  Melancholia,  Stupor  and  Dementia,  atten- 
tion, both  passive  and  active,  maj^  be  said  to  be  absent,  whilst 
in  Obsessional  cases  passive  hyper -attention  maj^  be  said  to 
be  automatic. 

Summary. — The  Psj^chology  that  has  been  described 
in  the  foregoing  chapters  is  to  be  regarded  as  a  dissection 
of  mental  processes  with  their  relationships  and  evolution. 
As  has  been  already  mentioned,  the  synthesis  or  sum  of 
these  processes  at  any  one  moment  represents  the  ego  or 
soul  of  the  individual  in  the  miity  of  Consciousness.  Sensa- 
tion, with  its  cognitive  element  and  its  affective  tone,  is  the 
primary  factor  in  our  mental  life.  Sensation  is  due  to  the  assi- 
milation of  molecular  motion  which  has  become  transformed 
^Adthin  the  organism.  Mental  operations  should  be  regarded 
in  the  same  light  as  the  phenomena  representing  the  reflex 
arc  on  the  lower  planes  of  the  nervous  system.  The  subjective 
aspect  of  the  reflex  arc  begins  with  sensation  in  Consciousness 
and  ends  in  action  or  conduct  (unless  dissipated  in  reflection), 
the  middle  or  highest  part  of  the  arc  being  occupied  by  thought 
and  emotion. 

Memory  is  a  fundamental  process  of  neural  activity,  and 
is  developed  from  a  species  of  primordial  memory  that  per- 
vades all  protoplasmic  organisms.     Thus,  a  nervous  current 


INSTINCT,    VOLITION,   AND   ATTENTION 


69 


or  synaptic  impression  tends  innately  to  be  remembered. 
Were  it  not  so,  mental  development  would  be  impossible. 
From  sensations,  special  and  organic,  are  developed  perceptions 
^^dth  their  associated  tones  of  feeling.  As  perception  presup- 
poses the  memory  of  previous  sensations,  so  ideas  or  thoughts 
are  the  revived  memory  images  of  past  perceptions,  and  the 
so-called  faculty  of  memory  becomes  developed.  Ideas  have 
their  correlated  and  connected  tones  of  feeling,  the  complexity 
of  which  forms  the  emotions,  the  more  intellectualised  of  these 
latter  being  the  basis  for  the  moral  and  other  sentiments.  The 
result  of  ideational  associations  unless  expended  in  introspective 
thought,  are  acts  of  Will  or  volitions,  just  the  same  as  the 
effects  of  emotional  states  are  instincts  or  instinctive  desires 


SENSATIOM\— ><.—   MEMORY 


IDEATION 


SENTIMENTS      ATTEMTIOH  — > — >^  ACTION 


EMOTION      ___,--'' 

Fig.   19. — ^Diagram  of  mental  processes. 

to  act.  These  latter  form,  indeed,  the  fundamental  basis  for 
action  which  Will  directs,  inhibits,  or  controls  according  to 
the  implantation  of  its  dispositions .  Thus  are  displayed  the  full 
conative  forces  of  the  individual.  The  process  of  attention 
comes  into  play  throughout,  being  active  in  the  higher  plane 
and  passive  in  the  lower. 

As  all  these  mental  processes  are  so  closeh'  connected  and 
are  interdependent,  it  is  scarcely  possible  for  one  process  or 
function  to  be  disordered  without  implication  of  the  others. 
Mind,  indeed,  energises  as  a  whole,  although  its  manifesta- 
tions in  health  or  disorder  maj  be  more  evident  in  one 
direction  than  in  another. 

A  person's  mental  reaction  is  dependent  on  the  elaboration, 
quality,  and  stabihty  of  the  brain  cortex,  A\ith  which  he  has 
been  furnished  by  his  forefathers,  and  by  the  moral  discipline 


70  MENTAL   DISEASES 

and  experience  to  which  he  has  been  subjected.  His  natural 
endowments  are  due  to  the  stock  whence  he  springs,  although 
even  then  a  degree  of  uncertamty  occurs  as  to  his  essential 
nature,  for  positive  knowledge  is  at  present  wantmg  to  foretell 
what  mental  traits  or  transmissible  units  have,  or  have  not,  been 
inherited  in  any  given  case.  His  future  training  and  acquire- 
ments are,  however,  matters  under  control  by  educational 
means,  subject  to  his  constitutional  vitality  and  to  the 
inherent  potentialities  of  his  cerebral  cortex.  These  potential- 
ities are  dependent  on  nervous  structure  and  function  and 
explain  personalities  in  different  individuals,  as  well  as  the 
characteristics  of  the  various  races.  Thus  the  white  man,  the 
black  man,  the  Anglo-Saxon,  the  Celt,  the  Slav,  the  Jew,  vary 
in  their  feelings  and  ideas,  not  in  accordance  with  civilisation, 
custom,  and  training  onh',  but  probably  also  in  the  essential 
bio-chemical  quality  of  nervous  tissue.  So  also  the  study  of 
the  ps3'chology  of  sex  leads  one  to  regard  the  egoistic  traits 
in  men  and  the  altruistic  tendencies  in  women  to  be  chiefly 
dependent  on  organisation.  Women  react  quicker  because 
their  actions  are  based  more  on  their  emotions  than  is  the 
case  with  men,  who  are  given  more  to  deliberation  before 
coming  to  conclusions. 

The  medical  student  will  do  well  to  follow  out  mental 
processes  as  far  as  possible  on  a  neurological  basis.  Without 
this,  he  is  apt  to  get  into  psychological  depths  and  to  traffic 
with  words  which  for  him  will  have  no  defuiite  meaning.  He 
will  find  that  in  msanity  there  is  bodily  disorder,  as  in  other 
departments  of  Medicine,  although  the  disorder  is  necessarily 
more  intricate,  concerned,  as  it  is,  principally  "with  such  a 
complex  structure  as  the  Cortex  Cerebri.  He  will  learn  that 
processes  occur  in  Mental  Diseases  which  are  often  but  an 
exaggeration  rather  than  a  perversion  of  those  occurring  in 
sane  indi\aduals.  He  "vvill  realise  that  insanity  is  due  largely 
to  an  arrested  evolutionary  state  or  to  a  partial  and  irregular 
dissolution  or  dissociation  of  brain  faculties,  as  exhibited  in 
disorder  of  feelings, ideas,  and  actions  and  in  failure  of  volmitary 
attention  and  higher  control. 


CHAPTER   VI 
THE    DIAGNOSIS    OF    INSANITY 

The  differentiation  of  the  forms  and  varieties  of  insanity 
from  one  another  will  be  referred  to  later,  when  considering 
them  individually.  It  is  here  proposed  to  inform  the  student 
of  certain  principles  which  will  enable  him  to  determine  whether 
a  person  is  insane  or  not,  and  to  give  him  some  guide  as  to 
the  means  of  examining  a  patient  with  regard  to  his  mental 
condition. 

At  the  outset  it  should  be  mentioned  that  mental  dis- 
order can  exist  without  insanity,  and  also  that  insanity  differs 
in  the  legal  sense  in  its  application  to  certain  circumstances, 
such  as  the  making  of  a  will,  or  the  determination  of  responsi- 
bility for  a  crime,  to  which  attention  will  be  directed  in  a 
subsequent  chapter.  In  the  ordinary  medical  sense,  insanity 
is  such  unsoundness  of  mind  as  renders  a  person  a  fit  and 
proper  person  to  be  detained  under  care  and  treatment,  and 
to  be  certified  as  such. 

Conditions  resembling  Insanity. — These  are  usually 
excluded  from  the  category  of  technical  insanity  by  reason  of 
their  temporary  nature,  or  of  the  slight  degree  of  mental 
aberration  displayed.  They  may,  however,  gravitate  into 
actual  insanity,  owing  to  the  persistence  or  increase  in  acuteness 
of  their  symptoms.     These  include — 

Delirium  from  such  diseases  as  Pneumonia,  Typhoid, 
Typhus,  Septicaemia,  Uraemia,  Rheumatic  Fever,  Malaria, 
Cerebral  Meningitis  and  Concussion.  These  can  usually  be 
diagnosed  with  ease,  and  in  most  cases  there  is  pyrexia.  In 
the  absence  of  bodily  complications  it  may  be  said  that  there 
is  no  rise  of  temperature  in  insanity  except  in  Acute  Delirious 
Mania,  in  some  Puerperal  cases,  in  the  congestive  seizures  of 
General  Paralysis,  and  in  Status  Epilepticus. 


72  MENTAL   DISEASES 

Intoxication. — Alcoholism  is  both  a  cause  and  a  symptom 
of  insanity.  Drunkenness  (or  Inebriation),  which  is  its  tem- 
porary manifestation,  is  not  legally  regarded  as  insanity j  whilst 
Delirium  Tremens  is. 

Drug  States,  such  as  are  induced  hy  Opium,  Morphia, 
Cocaine  and  other  sedatives.  These  exhibit  mental  symptoms 
which,  when  transient,  are  also  excluded  from  insanity. 

Aphasia  may  be  accompanied  by  little  mental  disturbance, 
the  patient  being  able  to  express  himself  reasonably  by  signs 
and  gestures.  In  other  cases  it  is  associated  with  insanity, 
as  are  some  other  conditions  due  to  Gross  Brain  lesions. 

Hypochondriasis  is  also  generally  differentiated,  if  of 
mild  nature  and  unaccompanied  by  suicidal  tendencies,  and 
if  it  does  not  interfere  with  the  patient's  ordinary  course  of  life. 

Hysteria  frequently  produces  strange  conduct,  mostly 
due  to  suggestion,  but  it  does  not  usually  mean  certifiable 
insanity. 

Eccentricity,  unless  suddenly  acquired,  or  very  pro- 
nounced, and  involving  interference  with  others,  is  hardly  to 
be  reckoned  as  insanity. 

Other  Conditions  that  might  be  mentioned  are  Som- 
nambulism, H3^pnotic  Trance,  Coma,  mild  states  of  Neur- 
asthenia, Psychasthenia,  or  of  Depression  (some  of  which, 
however,  are  liable  to  pass  the  border-line).  Criminality  is 
usually  distinguishable  from  insanity  but  may  be  associated 
with  it. 

One  more  condition  demands  special  notice,  viz.  :■ — ■ 

Feigned  Insanity — Although  now  and  then  an  insane 
person  with  delusions  says  he  is  feigning  disorder  in  order  to 
escape  punishment  for  an  imaginary  crime,  the  malingerer 
always  has  some  real  motive  in  endeavouring  to  produce  de- 
ception. It  is  not  infrequent  in  soldiers  and  sailors  who  desire 
to  obtain  their  discharge.  It  occurs  sometimes  in  work- 
houses to  enable  an  inmate  to  be  released  from  manual  work. 
Occasionally  an  undesirable  person  is  anxious  to  be  certified 
and  he  assumes  a  false  name  to  escape  police  vigilance,  or,  as 
has  happened,  a  person  tries  to  gain  admission  to  an  asylum 
for  newspaper  purposes,  or  a  criminal  feigns  insanity  to  avoid 
prison,  or  in  the  hope  of  being  transferred  from  prison  to  an 
asylum. 


THE   DIAGNOSIS   OF   INSANITY  73 

The  symptoms  and  signs  are  invariably  overacted  and  can 
usually  be  detected  by  careful  observation  and  close  watching. 
Sleeplessness,  incoherence,  refusal  of  food,  etc.,  are  difficult 
to  continue  or  simulate  for  any  length  of  time,  and  when  the 
person  thinks  he  is  unobserved,  he  remains  normal.  The  most 
difficult  cases  are  those  who  say  they  hear  "  voices." 

Definitions  of  Insanity. — Insanity,  as  its  etymology 
implies,  is  the  negation  of  sanity.  It  has  been  defined  as  a 
perversion  of  the  Ego.  This  is  correct  so  far  as  it  goes,  but 
the  Ego  is  not  a  constant  quantity  and  is  to  a  great  extent 
unknown.  Again  it  has  been  defined  as  disorder  of  conduct — 
but  conduct  may  be  regarded  as  far  from  normal  in  manj' 
original  or  eccentric  people,  in  religious  and  political  martyrs, 
and  in  criminals,  who  cannot  be  considered  insane. 

An  eminent  jurist,  the  late  Mr.  Justice  Stephen,  defined 
insanity  as  "  a  state  in  which  one  or  more  of  the  mental  func- 
tions are  performed  in  an  abnormal  manner,  or  are  not  per- 
formed at  all  by  reason  of  some  disease  of  the  brain  or  nervous 
system." 

Dr.  Maudsley,  in  the  opening  chapter  of  his  philosophic 
work  on  the  Pathology  of  Mind,  writes  :  "  By  insanity  of  mind 
is  meant  such  derangement  of  the  leading  functions  of  thought, 
feeling,  and  will,  together  or  separately,  as  disables  the  person 
from  thinking  the  thoughts,  feeling  the  feelings,  and  doing  the 
duties  of  the  social  body  in,  for,  and  by  which  he  lives." 

It  is,  however,  necessary  to  warn  the  student  not  to  give 
a  definition  of  insanity  in  a  court  of  law.  If  asked  for  one  in 
the  witness  box,  it  is  best  to  reply  that  insanity  assumes  so 
many  forms  that  it  is  impossible  to  frame  a  definition  which  is 
satisfactory  and  can  be  generally  accepted.  Thereby  he  may 
probably  save  himself  from  adverse  cross-examination  which 
might  discredit  his  case. 

Sanity  and  Insanity. — Mental  disorder  with  aberration 
of  conduct  amounting  to  insanity  may  be  recognised  at  once 
in  many  cases.  In  others  the  condition  may  only  be  slight, 
so  as  to  be  a  matter  of  diverse  opinion,  even  amongst  experts, 
and  to  be  dependent  on  the  personal  equation  of  the  physician. 
Insanity,  moreover,  may  be  latent  or  concealed,  so  that  it 
may  be  necessary  or  advisable  to  make  more  than  one  examina- 
tion of  the  patient  to  arrive  at  a  diagnosis. 


74  MENTAL   DISEASES 

The  onus  is  thrust  upon  the  medical  profession  in  the  first 
instance,  in  the  decision  as  to  whether  a  person  is  insane.  It 
must  be  remembered  that  every  person  is  regarded  as  sane  in 
the  eyes  of  the  law  until  it  has  been  proved  to  its  satisfaction 
that  he  is  insane.  No  medical  man,  however,  is  bound  to  accept 
the  responsibility  of  signing  a  certificate  of  insanity,  although 
if  he  believes  a  person  to  be  insane  and  has  sufficient  facts  to 
certif}^  to,  he  should  do  so  when  requested,  unless  he  has  good 
reasons  for  refusing. 

A  consultation  with  another  medical  man  is  frequent^ 
the  wisest  course  in  a  difficult  case.  If  a  person  is  insane, 
and  is  allowed  to  be  at  liberty,  there  are  the  risks  of  reckless 
extravagance  and  ruin  to  be  faced,  or  may  be  of  suicide  or  of 
acts  of  violence,  or  he  may  at  any  rate  be  a  nuisance  to  those 
about  him.  On  the  other  hand,  if  certified  as  insane  -without 
adequate  justification,  there  is  the  possibility  of  legal  action 
for  interference  mth  the  liberty  of  the  subject.  Both  con- 
tingencies have  to  be  considered,  and  the  practitioner  must 
show  his  force  of  character  in  coming  to  a  right  decision. 

To  ascertain  the  mental  state  of  an  alleged  patient,  a 
careful  examination  is  therefore  necessary.  This  mil  include  : 
(1)  an  analysis  of  his  mental  faculties  so  far  as  this  can  be 
arrived  at  by  observing  his  conversation  and  conduct,  and 
his  replies  to  various  questions ;  (2)  an  examination  of  his 
special  senses  and  general  bodily  condition.  Particular  notice 
should  be  taken  of  anything  that  the  patient  says  and  does 
which  point  to  mental  derangement. 

As  much  evidence  as  possible  concerning  the  patient's 
general  behaviour  should  be  obtained  beforehand  from  the 
relatives,  and  from  others  who  are  acquainted  with  him, 
especially  from  any  nurse  who  happens  to  be  in  attendance. 
From  the  relatives,  also,  must  be  gathered  facts  concerning 
the  previous  illnesses  and  the  personal  and  family  history  of 
the  patient.  Their  evidence  must  be  weighed  carefulh^  In 
some  instances  there  will  be  found  a  tendency  to  exaggeration 
in  their  statements,  but  more  commonly  they  minimise  the 
sjrmptoms  and  the  signs  of  disorder  with  a  view  to  prejudicing 
the  opinion  of  the  medical  attendant. 

Insanity  may  be  either  a  process  of  arrested  development 
or  one  of  dissolution  and  decay.     It  may  be  a  gradual  de- 


THE   DIAGNOSIS   OF   INSANITY  75 

formity  of  mind,  or  it  may  be  an  acute  disorder.  Often  it  is 
but  an  exaggeration  of  the  fluctuations  of  the  sane  mind,  and 
there  must  of  necessity  be  cases  which  are  on  the  border-hne. 

The  so-called  normal  mind  exhibits  in  many  individuals 
periods  of  temporary"  aberration,  of  depression  and  self- 
depreciation,  of  elation  and  overweening  confidence,  or  of 
irritability  and  querulousness,  yet  we  hesitate  to  designate 
these  changes  of  mood  as  insanity.  Then  again,  the  insane 
person  sometimes  has  his  lucid  intervals  and  freedom  from 
impulses,  his  conversation  and  conduct  being  apparently 
normal,  yet  the  improvement  too  often  is  only  transient,  and 
he  relapses,  so  that  he  is  rightly  regarded  as  insane. 

La  what  the  lawyers  call  Partial  Insanity,  a  patient  may 
often  be  found  to  converse  rationally  on  abstruse  subjects 
which  are  outside  his  particular  delusional  sphere,  and  thus 
he  may  pass  as  an  apparently  sane  individual.  It  must  be 
noted,  in  this  respect,  that  not  all  the  constituent  mental 
elements  are  necessarily'  affected  in  an  insane  person,  and 
that  mental  derangement  may  show  itself  in  one  direction 
only,  and  thereby  incapacitate  an  individual  from  living  as  a 
free  agent.  Eccentric  people  or  cranks  occupy  a  neutral 
position ;  their  ideas  and  conduct,  according  to  the  degree  of 
abnormality,  tending  towards  sanity  or  insanity. 

There  is  in  insanity  a  maladjustment  of  the  individual  to 
the  environment  of  everyday  life,  like  a  square  peg  fitting 
into  a  round  hole,  and  until  the  misfit  can  be  remedied,  friction 
and  social  discord  must  ensue.  Such  maladjustment  is  the 
essence  of  insanity.  It  is  fraught  with  dire  results  as  regards 
the  patient,  and  it  often  leads  to  injurious  effects  on  the  envi- 
ronment and  its  component  units.  According  to  the  degree 
of  insanity  which  the  patient  exhibits  must  his  environment 
be  especially  adapted  for  him,  to  promote  his  recovery  and  to 
protect  societ3^ 

Amongst  savages,  as  has  already  been  mentioned,  the 
insane  one  is  either  neglected,  or  done  to  death.  He  is  of  no  use 
to  his  community,  and  he  is  therefore  in  truth  "  put  away." 
With  the  spread  of  civilisation,  methods  have  been  devised  for 
dealing  vvith  disorders,  physical,  mental,  or  moral.  All  cases 
of  departure  from  the  normal  find  a  refuge  either  in  a  hospital, 
asylum,  or  house  of  correction,  where  proper  attention  can  be 


76  MENTAL   DISEASES 

procured  in  the  endeavour  to  restore  the  person  to  his  normal 
condition.  It  is  frequently  a  subject  for  remark  that  many  of 
the  insane  are  so  orderly  and  rational  in  an  asylum,  but  fail 
in  these  respects  in  the  outside  world.  This  is  largely  due  to 
the  special  environment  created  for  them  when  placed  under 
care. 

Criminality. — Just  as  there  is  no  absolute  line  of  demar- 
cation between  sanity  and  insanity,  and  between  a  fit  of  de- 
pression and  an  attack  of  Melancholia,  or  between  a  spell  of 
excitement  and  an  outbreak  of  Mania,  so  is  there  no  exact 
division  between  a  certain  kind  of  insanity  and  criminality. 
There  are  many  cases  of  instinctive  criminality  which  can 
hardly  be  distinguished  from  moral  imbecility  or  degeneracy, 
and  it  becomes  a  question  whether  a  prison  or  an  asylum  is 
best  for  victims  of  such  disorder.  It  has  become  fashionable 
in  certain  quarters  to  regard  all  crime  indeed  as  moral  disease? 
and  to  look  upon  punishment  as  the  necessary  form  of  treat- 
ment for  its  cure.  Be  this  as  it  may,  the  student  of  Medicine 
should  approach  a  case  of  the  kind  with  an  unbiassed  attitude. 
He  should  bear  in  mind  that  there  is  a  recognised  distinction 
between  vice,  crime,  and  insanity,  and  he  should  seek  for  flaws  in 
the  mental  condition  outside  the  moral  sphere  as  far  as  possible, 
when  pronouncing  a  person  to  be  of  unsound  mind.  Moral 
defect,  congenital  or  acquired,  when  occurring  in  insanity", 
without  evidence  of  other  mental  disorder,  renders  it  difficult 
to  supply  a  satisfactory  certificate.  This  is  also  the  case 
when  a  person  is  subject  to  uncontrollable  impulses,  unless  it 
can  be  proved  that  he  is  liable  to  fits  of  unconsciousness, 
or  to  states  of  automatism.  Criminal  tendencies,  however, 
are  frequently  the  outcome  of  delusions  and  hallucinations, 
which  make  the  diagnosis  the  easier,  especialty  if  there  have 
been  previous  signs  of  mental  disorder. 

Environment. — In  testing  the  mental  condition  of  any 
person  and  passing  judgment  on  his  conduct,  the  surrounding 
circumstances  should  always  be  taken  into  account.  Most, 
if  not  all,  actions  are  in  reality  responses  to  stimuli  from  the 
environment,  and  therefore  the  medium  in  which  the  indi- 
vidual is  placed  requires  consideration.  Conduct,  which  in 
one  person  or  in  one  set  of  circumstances  can  be  regarded  as 
insane,  may  in  another  person  or  in  other  conditions  be  con- 


THE   DIAGNOSIS   OF  INSANITY  77 

sidered  norma] .  Variations  from  ordinary  grooves  of  conduct 
must  not,  however,  necessarily  be  regarded  as  abnormal,  and 
the  student  must  be  on  his  guard  not  to  attribute  every  devia- 
tion from  well-beaten  paths  as  being  due  to  disease  or  disorder. 
Some  play  of  originality  must  indeed  be  allowed  for  in  a  certain 
proportion  of  people.  Insanity  is,  however,  often  manifested 
as  a  departure  from  the  social  usages  of  the  state  of  life,  to 
which  the  person  has  been  accustomed.  No  standard  can  well 
be  set  up,  for  of  what  use  is  it  to  compare  the  conduct  of  a 
man  of  education  and  culture  with  that  of  a  tramp  or  of  a 
savage,  considering  that  their  environments  and  reactions 
vary  so  much  in  comparison  with  one  another.  Again,  racial 
characteristics  must  be  taken  into  account  amongst  civilised 
nations. 

What  is  most  noticeable  about  the  insane,  as  a  class,  is  their 
lack  of  social  qualities.  They  like  to  be  alone,  and  take  but 
little  interest  in  one  another  and  in  their  surroundings,  this 
being  due  to  a  general  failure  of  attention,  A  minority  only 
have  increased  affections  or  a  craving  for  the  society  of  others, 
and  any  pretence  to  altruism. 

Mental  Wrecks. — In  severe  degrees  of  Idiocy,  patients 
are  quite  unable  to  guard  themselves  against  common  dangers 
and  pitfalls,  and  have  to  be  cared  for  in  all  respects  like  little 
children.  Not  far  removed  from  these  are  profound  Dements 
who  are  bereft  of  normal  habits,  such  as  the  instinct  of  cleanli- 
ness, and  whose  restless  antics  resemble  the  microkinetic  move- 
ments of  infants.  Many  are  disordered  in  the  primary  instinct 
of  eating,  and  bolt  their  food  or  neglect  it  altogether,  and  are 
given  to  acts  of  wanton  destructiveness,  being  quite  unable  to 
occupy  themselves  usefully.  Their  mindlessness  is  exhibited 
in  the  vegetative  life  they  lead,  in  their  want  of  expression 
and  in  their  mutism.  At  other  times  they  find  an  outlet  for 
their  energy  in  incoherence  and  meaningless  noises.  Such 
cases  are  easy  enough  to  diagnose,  and  although  past  recovery 
much  may  nevertheless  be  done  to  correct  their  morbid 
tendencies.  Their  bodily  health  is  not  up  to  the  average  by 
any  means,  as  is  generally  supposed.  Every  case  of  insanity, 
indeed,  shows  some  lowering  of  nutrition,  but  the  organic 
functions  for  the  most  part  are  performed  satisfactorily,  so  that 
many  mental  cases  reach  an  advanced  age,  unless  life  is  cut 


78  MENTAL   DISEASES 

short  by  intercurrent  ailments,  of  which  Phthisis  and  Pneu- 
monia are  the  most  prevalent. 

Incipient  Insanity. — It  is,  however,  in  the  premonitory 
and  early  stages  of  mental  disease,  and  in  its  slighter  degrees, 
that  the  chief  difficulties  are  presented  as  regards  diagnosis. 
Many  patients  are  then  considered  as  cases  of  Neurasthenia 
or  Hj^steria  onl}',  and  as  a  rale  command  scant  attention. 
The  first  indications  may,  indeed,  merely  be  regarded  b}'^  the 
relatives  as  those  of  a  so-called  "  nerve  case  "  or  of  a  "  liver 
attack,"  although  the  characteristics  of  a  mental  breakdown 
may  already  be  apparent.  The  most  usual  signs  are  insomnia, 
restlessness  and  irritability,  sensory  and  emotional  disturb- 
ances, change  of  character,  failure  of  attention,  and  neglect  of 
usual  occupations.  The  relatives,  however,  later  begin  to  be 
alarmed  as  to  what  is  really  going  to  happen.  Under  suitable 
conditions  some  undoubtedly  recover  in  home  surroundings ; 
in  others  the  attack  develops  further,  and  the  patient  has  to 
be  certified  for  special  care.  This  is  often  a  matter  of  anxiety 
to  the  practitioner,  and  he  is  only  too  glad  to  seek  expert 
advice,  when  the  opportunity  is  given.  The  asylum  physician 
may  have  no  difficulty  in  gauging  the  patient's  insanity;  it 
is  in  regard  to  an  accurate  prognosis  of  the  case  that  his  ex- 
perience and  judgment  will  be  most  severely  tested,  and  his 
anxiety  is  chiefly  felt  when  supervision  is  relaxed  as  a  suicidal 
patient  begins  to  convalesce. 

The  Patient's  Insight. — In  ordinary  physical  maladies 
mental  symptoms  are  for  the  most  part  insignificant,  and 
attract  but  little  attention.  The  patient  complains  of  pain, 
or  feels  out  of  sorts,  and  generally  consults  the  doctor  of  his 
own  accord.  But  in  mental  disease,  although  it  is  in  reality 
bodily  disease  in  which  mental  symptoms  are  predominant, 
the  case  is  different.  The  relatives  or  friends  usually  ask  for 
medical  advice  on  the  patient's  behalf.  The  latter  frequently 
has  no  proper  "  insight  "  into  his  condition  and  saj^s  there  is 
nothing  the  matter  with  him,  or  if  he  has  troubles  he  magnifies 
them  out  of  all  proportion. 

Mental  Gases  in  Private  Practice. — There  is  not  alto- 
gether the  same  difficult}^  in  diagnosing  insanity,  and  in  de- 
ciding on  the  necessit}^  for  certification  in  a  patient  already 
well  known  to  the  practitioner,  as  there  is  in  the  case  of  a 


THE   DIAGNOSIS   OF   INSANITY  79 

complete  stranger.  In  the  latter  event  he  should  obtain  if 
possible  some  accomit  of  the  patient  from  those  who  have  been 
associating  with  him.  A  medical  man  may  be  requested  either 
by  the  relatives,  or  by  a  Justice,  or  by  the  Lunacy  Commis- 
sioners, to  visit  a  patient,  in  his  home,  in  a  workhouse,  or  in 
some  other  place,  to  give  his  opinion  as  to  whether  he  should 
be  certified  or  not ;  or  he  may  be  asked  to  report  on  a  patient 
already  detained  in  an  institution. 

Guide  to  Examination. — The  medical  officer  of  an  asjdum 
in  examining,  and  taking  the  history  of,  a  new  case  for  ad- 
mission, as  a  rule,  is  assisted  by  having  various  headings  in  his 
casebook  to  which  his  attention  is  specially  to  be  directed. 
In  private  practice,  however,  no  definite  routine  can  generally 
be  carried  out,  and  the  investigation  of  a  mental  case  fre- 
quently involves  much  time  as  well  as  patience  and  tact.  An 
opinion  may  be  formed  that  a  patient  is  insane,  but  sufficient 
facts  may  be  wanting  to  supply  a  certificate  until  a  second 
interview  has  been  granted,  and  it  may  be  advisable  to  have 
the  patient  watched  in  the  meantime. 

Except  in  some  dangerous  and  rare  cases,  in  which  the 
practitioner  may  be  advised  to  see  the  patient  unannounced 
or  without  introduction,  he  should  never  attempt  to  disguise 
himself  or  pass  as  a  layman  or  under  an  assumed  name.  Such 
finesse  when  practised  inevitably  does  harm.  It  destroys  the 
patient's  confidence  in  his  medical  advisers,  and  renders  future 
treatment  more  difficult.  It  may  perhaps  be  best  in  some 
instances  not  to  mention  the  exact  purport  of  the  visit,  or 
possibly  it  may  be  stated  that  the  relatives  have  expressed 
anxiety  about  him,  and  that  they  consequently  desire  a  medical 
opinion  as  to  his  health.  Embarrassment  is  occasionally  felt 
by  both  patient  and  doctor  in  strained  circumstances,  the 
former  sometimes  being  very  impolite  and  the  latter  full  of 
apologies.  Occasionally  it  is  necessary  to  obtain  admittance 
to  the  patient's  house  by  force  ;  in  such  case  it  is  best  to  obtain 
an  order  from  a  Justice  for  the  visit.  As  a  rule,  however,  there 
is  no  more  difficulty  in  gaining  access  to  a  mental  patient  than 
to  any  other  person  requiring  a  medical  examination. 

The  medical  student  has  been  taught  to  make  an  investi- 
gation of  the  bodily  organs  and  functions  seriatim  in  ordinary 
diseases,  and  he  should  likewise  in  cases  of  suspected  insanity 


80  MENTAL   DISEASES 

make  as  far  as  possible  a  systematic  inquiry-  into  the  various 
mental  functions.  He  should  test  the  patient's  special  senses, 
his  perception,  ideation  and  vohtion,  his  emotions,  sentiments 
and  instincts,  together  "wdth  the  faculties  of  memory"  and 
attention. 

Patient's  History. — WTien  taking  the  personal  and  family 
history  of  the  patient  from  his  relatives,  inquiry  should  be  made 
as  to  his  previous  illnesses,  and  as  to  his  inheritance,  not  only 
regarding  insanit}^,  but  also  epilepsy,  alcohohsm,  etc.  The 
assigned  causes  of  the  mental  breakdown  should  be  ascer- 
tained, together  with  its  duration  and  mode  of  development. 
Inquiries  should  be  directed  to  the  following  points  :  Has 
there  been  a  previous  attack  ?  What  change  in  the  habits 
and  course  of  life  of  the  patient  has  recently  taken  place  ? 
Is  he  dijfferent  from  his  usual  self  ?  Is  he  sleepless  or  rest- 
less ?  Is  he  able  to  continue  his  occupation  ?  Has  he  been 
addicted  to  alcohohsm  or  drugs  ?  Has  he  been  leading  a 
loose  life  ?  Has  he  ever  had  a  fit,  and  if  so  what  was  its 
nature  ?  In  some  cases  it  may  be  as  well  to  probe  back  into 
his  childhood.  Was  he  backward  in  learning  to  talk  or  walk  ? 
Was  he  subject  to  convulsions  or  night  terrors  ?  Was  he  dull 
or  precocious  at  school  ?  Did  he  take  part  in  games  ?  What 
were  his  earlv  character  and  temperament  ? 

The  Examination  of  the  Mental  State. — Take  care 
you  address  the  right  person,  if  the  patient  is  in  the  company  of 
others.  Observe  Ms  general  appearance,  his  facial  expression, 
his  attitude,  his  movements  and  gestures.  Is  his  attire  untid}" 
or  unduly  decorative  ?  Take  stock  of  his  surroundings.  After 
some  conventional  form  of  greeting  or  address,  the  conversa- 
tion ma}'  be  opened  b}^  inquiry  as  to  his  health,  or  by  reference 
to  the  topics  of  the  day.  Ascertain  his  age  and  his  civil  state. 
Gradually  questions  may  be  put  to  him  regarding  any  special 
troubles  or  worries  he  might  have.  Ask  him  how  he  gets  on 
with  his  work,  or  his  hobbies.  His  responses  will  indicate  in 
some  measure  his  mental  reactions.  They  may  be  brisk,  slow, 
friendly,  hostile,  frank,  or  suspicious ;  or  there  ma}"  be  no 
response  at  all;  or  the  patient  may  betray  negati^nsm.  The 
character  of  his  speech  should  be  noted,  such  as  difficulty  in 
articulation,  slurring,  hesitanc}',  stammering,  etc.  Can  he 
fix  his  attention  on  what  is  said  to  him  ?     Does  his  memory 


THE   DIAGNOSIS   OF  INSANITY  81 

show  impairment  either  for  recent  or  remote  events  ?  Note 
also  the  association  of  his  ideas.  Are  his  associations  slow  or 
quick  ?  Does  he  appear  to  have  few  or  many  ideas,  consider- 
ing his  education  and  position  in  life  ?  Is  he  obsessed  by  a 
narrow  train  of  thought  ?  Has  he  imperative  ideas  ?  Does 
he  repeat  himself  unduly  or  does  his  conversation  wander  ? 
Is  he  confused,  verbigerent,  or  incoherent  ?  Can  he  calculate 
figures  accurately  ? 

Does  he  narrate  what  is  manifestly  delusional,  or  are  his 
statements  based  on  facts  which  have  been  exaggerated  by 
disordered  judgment  or  emotion,  and  has  he  lost  all  sense  of 
proportion  ?  Compare  his  statements  with  those  of  his 
relatives.  Some  delusions  are  difficult  to  prove,  e.  g.  when  a 
jealous  wife  asserts  infidelity  on  the  part  of  her  husband,  and 
vice  versa.  Other  delusions  are  difficult  to  elicit,  the  patient 
purposely  concealing  them,  as  often  happens  when  a  patient 
has  been  certified  before.  Sometimes  delusions  are  best  shown 
in  letters  or  diaries.  Examine  the  handwritmg  for  repetitions 
or  omissions  of  letters  and  words.  Ask  the  patient  how  he 
sleeps,  and  if  he  has  dreams  whether  they  disturb  him  or  not. 
If  on  the  other  hand  he  is  sleepless,  ascertain  if  this  is  due  to 
anxious  thoughts  or  not. 

The  next  step  is  the  patient's  emotional  state.  Is  he 
depressed,  elated  or  apathetic  ?  Does  he  exhibit  calnmess  or 
excitement,  and  does  his  state  change  during  the  interview  ? 
Does  he  evince  hatred  against  any  one  without  provocation, 
and,  if  so,  has  he  any  weapons  about  him  ?  If  depressed,  ask 
how  far  he  has  lost  interest  in  life,  and  what  are  his  feelings 
towards  his  family,  and  elicit  any  tendency  to  suicide.  Find 
out  the  patient's  explanation  of  his  condition.  If  elated  and 
excited,  he  will  probably  be  loquacious  and  full  of  misdirected 
energy,  and  he  will  very  likely  resent  any  notion  of  being  con- 
sidered ill  at  all.  If  apathetic  and  devoid  of  all  emotion,  is 
this  due  to  extreme  confusion,  or  is  he  stuporous,  demented,  or 
congenitally  deficient  ? 

Examine  his  special  sense  organs,  and  if  any  are  disordered, 
determine  whether  such  disorder  is  due  to  peripheral  or  central 
causes,  or  to  a  combination  of  both.  Test  his  perception  with 
regard  to  each  sense.  Does  he  comprehend  ordinary  objects 
and  know  how  to  use  them  ?     Is  he  correctly  orientated — does 


82  MENTAL  DISEASES 

he  know  where  he  is,  and  can  he  name  the  day  or  month  of 
the  year  ? 

Is  he  troubled  with  illusions  or  hallucinations  ?  Has  he 
any  delusions  as  to  identity  ?  Is  he  subject  to  visions,  or 
imaginary  noises,  whisperings,  mutterings  or  "  voices,"  by 
night  or  by  day  ? — ^A  patient  with  aural  hallucinations  some- 
times puts  cotton-wool  or  wax  in  his  ear,  turns  his  head  round 
suddenly  as  if  listening  during  a  pause  in  conversation,  or 
replies  to  "  voices  "  audibly  or  by  gestures. — Does  he  complain 
of  disagreeable  smells,  or  say  that  his  food  tastes  bad  and  that 
he  is  unable  to  eat  it  ?  Has  he  any  anaesthesia  or  hypochon- 
driacal sensations  about  his  head  or  body,  or  in  connexion 
with  his  sexual  organs  ?  Is  he  abnormally  erotic  or  given  to 
masturbation  ? 

Inquire  as  to  his  recreations.  Is  he  active,  restless  or 
sedentary  ?  Is  he  given  to  peculiar  mannerisms  or  to  bad 
and  defective  habits  ?  Is  he  aggressive,  or  subject  to  acts 
of  indecision,  or  to  impulses  ?  Is  he  suicidal  or  dangerous  ? 
Does  he  exhibit  loss  of  control  by  words  or  actions  ? 

The  Physical  Condition. — Observe  the  complexion  and 
general  nutrition  of  the  patient.  Take  his  weight  and  note 
any  loss.  Notice  any  cranial  abnormality,  or  stigma  of  de- 
generacy. Go  through  the  various  systems  of  the  body. 
Examine  the  tongue,  teeth,  throat,  and  thyroid,  and  the 
digestive  organs ;  ask  about  the  appetite,  and  any  tendency 
to  constipation.  Take  the  temperature  and  test  the  urine. 
In  women  inquire  as  to  the  menses.  Examine  the  heart  and 
liuigs,  and  take  the  pulse  rate  and  arterial  tension.  If  in 
doubt  as  to  Syphilis,  apply  the  Wasserman  test  both  to  the 
blood  and  cerebro-spinal  fluid,  remembering  that  a  negative 
result  is  no  proof  against  the  disease. — If  opportunity  be 
afforded  for  examining  the  cerebro-spinal  fluid  by  lumbar 
puncture,  the  presence  of  lymphocytosis  is  strong  evidence 
of  the  existence  of  General  Paralysis,  especially  if  plasma  cells 
are  also  to  be  seen.  An  ordinary  blood-count  is  rarely  necessary 
although  useful  in  some  Confusional  cases. 

Notice  if  the  extremities  are  warm,  cold,  cyanotic,  or 
swollen,  and  if  the  skin,  nails  and  hair  are  affected.  Look  for 
trophic  changes  and  for  any  bedsores,  bruises  or  marks  of  in- 
jury.    Observe  the  patient's  gait,  the  hand  grasp,  the  muscular 


THE   DIAGNOSIS    OF   INSANITY  83 

development,  and  the  presence  or  absence  of  any  tremor  or 
paralysis.  Examine  the  reflexes,  superficial  and  deep,  especi- 
ally the  laiee-jerks  and  plantar  response,  taking  note  of  any 
extension  of  the  big  toe  (Babinski).  The  eye  movements 
should  be  carefull}-  tested  as  well  as  the  pupillarj"  reactions 
to  light  and  accommodation,  to  see  if  the  Argyll-Robertson 
phenomenon  is  present.  Note  the  size  and  shape  of  the 
pupils,  and  the  extent  of  the  visual  fields,  and  if  there  is  an}^ 
nystagmus.     In  some  cases  examine  the  fundus  oculi. 

Be  careful  not  to  miss  any  phj'sical  signs  of  General  Paratysis 
in  a  male  case  between  35  and  50,  and  examine  the  patient 
directty  or  indirectly  for  Syphilis. 

Make  Notes. — Lastty,  during  or  after  the  examination 
make  some  notes.  Do  not  forget  to  include  the  date,  the 
Christian  name  and  surname,  the  occupation  and  address  of 
the  patient  as  well  as  those  of  any  informants  in  the  case.— 
These  will  be  required  if  the  patient  is  certifiable,  and  a 
certificate  is  advisable,  remembering,  however,  that  a  patient 
may  be  insane  without  necessarily  being  officially  placed  under 
care  and  treatment. 

It  is,  of  course,  not  requisite  or  possible  to  make  a  com- 
plete examination  of  every  patient  who  is  deemed  to  be  in- 
sane ;  many  cases,  indeed,  present  no  difficult}^  in  coming  to  a 
conclusion,  and  a  certificate  can  be  supplied  without  much 
hesitation. 

The  diagnosis  of  insanity  depends  on  a  combination  of 
sjTuptoms  and  signs,  the  result  of  disorder  of  brain  function. 
This  is  chiefly  to  be  observed  by  the  ideas  a  patient  expresses, 
the  moods  to  which  he  is  subject,  and  the  conduct  he  displays. 
All  of  these,  being  at  variance  with  his  normal  condition, 
render  him  unfit  to  look  after  himself  and  his  affairs,  or  to 
be  at  large  without  supervision. 


CHAPTER   VII 
GENERAL    CAUSATION 

Iisr  the  majority  of  cases  of  mental  breakdown,  there  are 
certain  conditions  in  the  past  history  of  the  patient  which 
may,  with  reason,  be  considered  to  have  had  a  definite  relation- 
ship to  the  attack  of  mental  disorder. 

These  antecedents  are  regarded  as  causes,  after  careful 
scrutiny,  so  as  to  eliminate  accidental  or  coincidental  condi- 
tions, which  in  the  light  of  scientific  knowledge  cannot  be  held 
as  contributory  factors  to  such  an  extent  as  to  affect  the 
Etiology.  Many  alleged  causes,  indeed,  are  largely  symptoms 
of  mental  disorder  only.  The  brain  being,  as  it  is,  in  connexion 
with  every  part  of  the  body  and  with  the  external  world,  and 
receiving  nourishment  from  the  circulating  blood,  its  mental 
and  other  functions  must  necessarily  be  affected  continually 
for  good  or  evil,  and  hurtful  influences  of  all  kinds  may  be 
regarded  in  a  sense  as  causes  of  insanity. 

Sometimes  a  case  of  insanity  presents  itself  in  which,  in 
spite  of  a  reliable  history  and  a  close  examination,  no  adequate 
cause  can  be  assigned,  and  as  a  result  the  return  has  to  be 
made  "  cause  unknown."  More  generally,  however,  it  is  a 
combination  of  possible  causes  that  has  to  be  dealt  with  in  a 
given  case. 

The  practitioner  must  be  wary  about  placing  too  much 
reliance  on  the  statements  of  relations  as  to  what  they  consider 
causes  of  mental  maladies.  Frequently  these  are  entirely 
erroneous,  sometimes  indeed  facts  are  wilfuUy  misstated  or 
omitted,  and  this  apphes  more  particularly  to  matters  of 
inheritance.  In  the  upper  classes  the  desire  is  to  minimise 
the  hereditary  stigma  as  much  as  possible,  and  to  find  a 
loophole  in  extraneous  circumstances,  whilst  in  the  pauper 
classes  their  ignorance  as  to  family  history  is  not  infrequently 

84 


GENERAL   CAUSATION  85 

surprising,  and  relatives  are  not  always  available.  In  recent 
years,  however,  close  investigation  has  been  given  to  the  whole 
subject  of  causation.  The  assigned  causes  of  every  certified 
case  are  carefully  considered  by  the  medical  officers  and 
pathologists  of  asylums,  so  that  the  information  from  the 
tabulated  statistics  of  the  Commissioners  may  be  regarded 
as  containing  facts  of  sufficient  value,  from  which  correct 
inferences  can  be  deduced. 

Certain  factors  can  be  reduced  to  one  sex  more  particularly, 
or  even  absolutely,  as  in  the  case  of  pregnancy  in  women  and 
its  consequences."  In  women,  also,  the  organisation  is  such  that 
they  are  more  affected  by  the  critical  periods  of  life,  and  their 
more  pronounced  emotional  nature  renders  the  so-called  mental 
influences  of  greater  significance.  Men,  on  the  other  hand,  are 
more  liable  to  the  evils  of  Syphilis  and  Alcohol. 

The  official  list  of  causes  and  associated  factors  of  insanity, 
which  has  to  be  used  in  Institutions,  is  somewhat  complex, 
and  will,  therefore,  not  be  specially  discussed.  The  list,  together 
with  the  various  percentages,  is  published  in  the  Annual  Report 
of  the  Commissioners  to  the  Lord  Chancellor. 

It  has  been  customary  to  differentiate  the  causes  of  insanity 
into — 

Predisposing  and  Exciting, 
Or  Congenital  and  Acquired, 
Or  Principal  and  Contributory, 
Or  Physical  and  Mental  or  Moral. 

In  later  years,  however,  it  has  been  usual  to  make  the 
following  main  division  of  causes  into — 

(1)  Heredity,  and 

(2)  Stress; 

which  will,  moreover,  enable  the  student  best  to  grasp  the 
causation  of  insanity,  using  the  word  Heredity  in  a  wide 
application,  and  Stress  (or  Strain)  as  comprising  both  physical 
and  mental  or  moral  influences. 

Heredity. — The  result  of  sexual  conception  is  dependent 
on  the  quahty  of  the  germ  and  sperm  cells,  and  on  the  suita- 
bility of  the  one  to  the  other,  which  is  largely  subject  to  the 
degree  of  sanguinity.   As  development  proceeds,  it  is  generally 


86  MENTAL   DISEASES 

obvious  that  the  offsprmg  resembles  its  parents  both  physically 
and  mentally,  and  it  becomes  a  matter  for  surprise  when  it  is 
otherwise.  It  is  not  proposed  to  refer  seriatim  to  the  different 
laws  of  inheritance,  so  far  as  they  are  known,  but  only  to 
mention  some  of  their  sahent  features.  Thus,  the  progeny 
tends  to  inherit  the  quahties  and  attributes  of  its  parents,  one 
or  both.  Attributes  that  are  common  to  both  parents  tend 
to  become  pre-potent.  Certain  attributes  may  be  transmitted 
by  one  parent  only,  and  appear  at  a  specified  time  of  life  in 
the  offspring.  The  transmission  of  attributes  may  also  be  in 
latent  form  and  skip  a  generation  (atavism). 

On  Mendel's  hypothesis  it  is  surmised  that  actual  "  units  " 
exist,  representing  certain  qualities.  All  of  these  units  may 
or  may  not  be  transmitted ;  they  may  even  be  segregated 
and  only  develop  in  a  succeeding  generation.  In  some 
instances  a  certain  ratio  as  to  transmission  has  been  found. 
This  is,  however,  difficult  to  establish  in  the  human  species, 
as  families  are  so  small.  Nevertheless  the  student  should  be 
acquainted  with  Mendelian  principles  as  they  seem  to  apply 
in  the  case  of  man,  for  instance  in  regard  to  eye  colour.  The 
pigmented  or  pure  brown  (or  hazel)  iris  is  dominant  over  the 
recessive  unpigmented  or  so-called  pure  blue  (or  grey)  iris,  so 
that  the  colour  brown  appears  in  hybrids,  but  the  colour  blue 
can  be  extracted  in  the  next  generation.  The  grey  or  blue 
eye  (which  colour  alone  is  present  at  birth  in  Western  nations) 
owes  its  appearance  to  the  purple  of  the  uvea  behind  the  iris, 
whereas  the  brown,  hazel,  or  green  eye  has  additional  pigment 
on  the  anterior  surface  of  the  iris,  and  sometimes  round  the 
pupil  only. 

The  following  results  are  interesting  and  are  generally 
accepted — using  the  term  Pure  as  opposed  to  Hybrid  : — 

The  union  of  pure  brown  eyes  and  pure  brown  eyes  produces 
pure  brown  eyes ; 

The  union  of  pure  blue  eyes  and  pure  blue  eyes  produces 
pure  blue  eyes ; 

The  union  of  pure  brown  eyes  and  pure  blue  eyes  produces 
hybrids  (brown) ; 

The  union  of  pure  brown  eyes  and  hybrids  (brown)  produces 
half,  pure  brown,  half,  hybrids  (brown) ; 


GENERAL   CAUSATION  87 

The  union  of  pure  blue  eyes  and  hybrids  (brown)  produces 
half,  pure  blue,  half,  hybrids  (brown) ; 

The  union  of  hybrids  (brown)  and  hybrids  (brown)  produces 
half,  hybrids  (brown),  quarter,  pure  brown,  and  quarter,  pure 
blue  eyes. 

Brown  eyes,  therefore,  are  either  pure  or  hybrids,  the 
latter  being  probably  commonest,  but  blue  eyes  are  always 
pure,  i.  e.  they  breed  true.  Blue  eyes  are  derived  from  blue 
eyes,  or  from  hybrids ;  but  never  from  pure  brown  eyes  (in 
the  first  generation).  The  above  is  an  instance  of  the  trans- 
mission of  one  quality  only,  and  has  been  confirmed  in  the 
case  of  the  length  of  the  vegetable  pea,  and  of  the  colour  of 
the  andalusian  fowl.  But  in  the  case  of  two  or  more  qualities, 
the  ratio  is  necessarily  different.  For  instance,  in  peas  with 
two  different  qualities  in  each  parent,  the  one  being  dominant 
and  the  other  recessive,  the  first  generation  is  a  hybrid  with 
the  two  dominants.  The  second  hybrid  generation  follows  a 
different  ratio,  viz.  in  every  sixteen  peas  there  will  be  nine 
with  two  dominants,  six  with  a  dominant  and  recessive  of 
either  kind  {i.  e.  three  plus  three),  and  one  with  the  recessive. 
It  is  possible  that  Mendelism  is  only  an  anomalous  form  of 
heredity,  and  it  is  doubtful  whether  it  can  be  applicable  to 
the  complexity  of  human  qualities  and  characteristics  gener- 
ally, but  this  is  a  matter  for  future  research.  It  may,  how- 
ever, be  said  that  the  characteristics  of  sanity  are  dominant 
over  those  of  insanity  and  this  is  in  accordance  with  Nature's 
effort  to  mend  a  stock,  or  else  to  end  it. 

Much  controversy  has  raged  over  the  possibility  of  the 
transmission  of  acquired  characteristics,  i.  e.  variations  derived 
from  the  individual's  life  experience.  Although  it  cannot  be 
denied  that  the  nutrition  of  the  germ  plasm  of  either  sex  is 
affected  by  the  body  generally  and  by  its  environment,  most 
authorities  adhere  to  Weissmann's  view  that  congenital 
variations  in  the  germ  plasm  alone  are  capable  of  transmission 
(mutism). 

In  mental  diseases,  experience  demonstrates  that  brain 
weakness  is  more  certainly  transmitted  through  the  mother 
and  more  particularly  to  the  daughters,  the  latter  being  on  an 
average  more  frequently  affected  than  the  sons.     Instability 


88  MENTAL   DISEASES 

of  the  nervous  system  is  what  is  transmitted,  and  it  shows 
itself  in  manifold  ways,  the  most  constant  of  which  is  a 
type  of  convolutional  constitution  in  which  the  association 
neurons  are  prone  to  disorder.  In  such  a  case  of  neuropathic 
inheritance  it  is  impossible  to  forecast  accurately  what  type 
of  disorder  is  likely  to  eventuate.  In  this  respect,  the  particular 
kinds  of  stress  that  operate  as  additional  factors  in  a  break- 
down have  considerable  influence  in  the  production  of  the 
insanity.  In  some  instances  the  morbid  transmission  is 
"  similar,"  thus  Melancholia,  i.  e.  depression  of  the  Maniacal- 
Depressive  group,  is  very  prone  to  breed  true,  so  also  is  Circular 
insanity,  and  to  a  certain  extent  this  applies  to  Paranoia.  A 
suicidal  tendency  is  particularly  liable  to  be  transmitted,  and 
it  frequently  manifests  itself  in  a  succeeding  generation  at  the 
same  time  of  life,  and  by  similar  devices.  In  this  respect  the 
force  of  imitation  plays  a  part.  The  tendency  to  Alcoholism 
likewise  betokens  an  unstable  nervous  system.  Nevertheless, 
drunkenness  in  the  offspring  is  not  infrequently  due  to  imitation. 
On  the  other  hand,  the  morbid  transmission  may  be  "  dissimi- 
lar," i.  e.  it  may  assume  different  types,  namely,  Epilepsy, 
Hysteria,  Neurasthenia,  Hypochondriasis,  Alcoholism,  Asthma, 
Chorea,  Migraine,  Stammering,  Tics,  Somnambulism,  Eccen- 
tricity, Moral  Degeneracy  and  the  different  degrees  of  Feeble- 
mindedness, Imbecility,  and  Idiocy.  These  transformations 
constitute  the  so-called  Insane  Diathesis,  used  in  its  widest 
sense. 

A  defective  nervous  system  often  shows  itself  by  a  want 
of  balance  or  lack  of  proportion  in  certain  aptitudes  or  mental 
functions — undue  precociousness,  excess  of  mathematical, 
musical  or  other  artistic  tastes,  with  corresponding  loss  of 
other  talents,  delayed  puberty,  sexual  perversions,  defect  of 
will  power  or  moral  sense,  anomalies  of  motor-sensory  function, 
and  other  stigmata  of  degeneracy.  Some  authorities  included 
metabolic  and  other  disorders  such  as  Diabetes,  Gout,  Rheu- 
matism, Phthisis,  etc. ;  but  these  can  hardly  be  included  in 
the  same  category,  although  marriage  with  those  affected  with 
these  conditions,  or  with  neuropaths  is  rarely  satisfactory. 

Hereditary  influence  is  said  to  be  "  direct  "  when  a  parent 
has  suffered  from  insanity  or  an  allied  neurosis,  and  "  colla- 
teral "  when  brothers  or  sisters,  aunts  or  uncles,  or  cousins 


GENERAL   CAUSATION  89 

are  affected.  In  the  Commissioners'  statistics,  however, 
heredity  excludes  cousins,  nephews  and  nieces,  and  offspring. 
A  person  with  a  bad  inheritance  from  both  father  and  mother, 
naturally  has  the  risk  of  inheritance  considerably  increased. 
This  universally  accepted  law  has  led  many  people  to  regard 
consanguinity  as  a  potent  cause  of  insanity.  The  ancient 
rulers  in  Egypt,  however,  are  credited  with  making  repeated 
incestuous  marriages  without  interfering  with  the  physical 
or  mental  virility  of  their  offspring.  Marriage  of  first  cousins 
does  accentuate  the  traits  of  the  parents  in  the  offspring,  but 
if  the  contracting  parties  and  the  family  stock  are  healthy 
and  stable,  such  unions  need  not  be  discouraged  on  strictly 
medical  grounds.  Moreover,  such  cousinship  may  be  largely 
accidental,  and  the  make-up  of  the  individuals  both  mentally 
and  physically  may  be  chiefly  from  the  unrelated  sources. 
It  cannot  be  accepted  that  a  person  inherits  half  from  each 
parent,  and  a  quarter  from  each  grandparent,  as  Galton 
originally  formulated. 

When  insanity  or  its  equivalents  are  pre-potent  in  a  family, 
as  shown  by  many  members  being  affected,  the  morbid  influence 
tends  to  appear  earlier  in  life  in  the  succeeding  generation 
(anticipation) ;  the  degenerative  psychoses  become  manifest, 
and  the  stock  is  finally  extinguished  by  sterility.  Were  this 
to  be  otherwise,  insanity  would  be  even  more  general  in  the 
population  than  it  is,  although  the  system  of  treatment  by 
segregation  necessarily  prevents  its  spread  in  a  great  measure 
and  assists  in  its  extinction.  When,  on  the  other  hand,  the 
neuropathic  taint  is  but  slight,  it  is  more  than  probable  that 
with  prudent  matrimonial  unions,  insanity  can  be  eradicated 
in  a  third  generation,  and  the  maleficent  units  may  escape 
further  transmission  altogether.  Mott's  valuable  researches 
into  pedigrees  and  family  histories  have  given  fresh  impetus 
to  the  study  of  inheritance.  In  the  London  County  Asylums, 
containing  about  20,000  patients,  he  has  found  amongst  them 
two  instances  of  six  in  a  family,  three  instances  of  five,  twelve 
of  four,  eighty-five  of  three,  and  752  of  two. 

Heredity  must  therefore  be  regarded  as  a  most  important 
factor  in  the  production  of  insanity;  yet,  when  a  morbid 
hereditary  influence  is  not  very  strong,  many  of  the  progeny 
remain  normal,  and  there  is  a  tendency  to  reversion  to  the 


90  MENTAL   DISEASES 

average  type,  which  should  be  a  solace  to  victims  of  possible 
mal-inheritance.  In  the  present  state  of  knowledge,  it  is 
impossible  to  say  for  certain  which  child  has,  and  which  has 
not,  the  seeds  of  insanity  within  it.  In  after  life  one  breaks 
down,  say,  with  Dementia  Prsecox,  another  is  saved  from 
insanity  only  by  extra  precautions  as  to  education,  training 
and  occupation  in  life,  whilst  the  rest  happen  to  be  reversions 
to  the  normal,  and  are  able  to  cope  with  the  ordinary  stresses 
of  life.  The  second  example  represents  a  type  of  the  poten- 
tially insane  person  who,  if  he  or  she  marries,  is  capable  of 
transmitting  insanity,  probably  as  much  as  any  certified 
person. 

Insanity  does  now  and  then  occur  in  a  family  in  which, 
after  all  possible  inquiry,  no  trace  of  serious  blemish  can  be 
ascertained  in  the  last  three  generations  and  there  seem  no 
adequate  external  causes.  It  may  in  such  a  case,  perhaps,  be 
due  to  reversion  to  some  remote  ancestral  flaw,  or  it  may  be 
a  novel  congenital  variation.  As  in  the  vegetable  kingdom 
a  bad  specimen  sometimes  arises  from  the  same  seed  along 
with  good  specimens,  so  it  is  probable  that  insanity  can  arise 
de  novo,  as  does  genius. 

Family  records  of  sane  people,  especially  with  regard  to 
parentage,  do  not  show  anything  like  the  proportion  of  morbid 
heredity  that  is  obtained  from  the  insane.  A  fair  estimate 
from  statistics  shows  that  in  the  sane  it  is  about  10  % — even 
if  Alcoholism,  Eccentricity,  etc.  are  included. 

A  history  of  insane  heredity  is  admitted  in  22-7  %  of  male 
cases  and  28*4  %  of  female  cases  received  annually  into 
asylums.  If,  however,  hereditary  instability,  as  exhibited 
by  Alcoholism,  Epilepsy,  etc.,  be  included,  these  figures  would 
be  increased  by  another  10  %  in  each  sex.  It  is  probable  that 
ignorance  and  mis-statements  render  these  figures  too  low, 
and  that  at  least  50  %  of  cases  of  either  sex  should  be  attributed 
to  transmitted  influences  of  various  kinds.  About  3|  %  of 
admissions  of  each  sex  reveal  signs  of  congenital  mental 
deficiency.  Sometimes,  when  no  cause  can  be  elicited,  the 
fact  of  innate  instability  comes  to  light  accidentally,  by  the 
knowledge  of  the  patient  having  been  under  care  elsewhere 
on  some  previous  occasion.  Many  cases  are  derived  from 
stocks  in  which,  although  devoid  of  insanity,  there  are  psychic 


GENERAL   CAUSATION  91 

stigmata  of  various  kinds,  e.  g.  people  who  are  weak-minded  or 
narrow-minded,  morbidly  impressionable  or  hypersensitive, 
highly  emotional,  suspicious  or  jealous — such  characteristics 
often  indicate  a  definite  flaw  in  mental  constitution  which 
may  be  transmitted  and  may  readily  develop  into  insanity  in 
the  presence  of  stress.  Such  brains  are  scarcely  on  a  level 
with  those  better  developed  ones  which  have  been  subjected 
to  an  attack  of  Acute  Mania  or  Melancholia,  yet  the  term 
heredity  is  not  usually  applied  to  the  former. 

Lastly,  it  must  be  mentioned  that  the  germ  plasm  may  be 
subject  to  deteriorating  influences  at  the  time  of  conception. 
Alcoholism  is  by  far  the  most  important  of  these,  but  an 
enfeebled  state  of  health  of  the  parents  from  many  causes 
must  be  added.  During  some  pregnancies,  especially  in 
illegitimacy  with  its  attendant  anxieties  and  privations,  there 
is,  from  neglect  of  the  destitute  mother,  not  a  fair  chance 
given  to  the  growing  embryo,  which  is  only  too  likely  to 
turn  out  defective  at  birth,  or  to  develop  mental  derangement 
in  later  life. 

Stress. — By  this  is  meant  the  operation  of  a  strain  on  the 
constitution  of  the  individual  in  excess  of  what  it  is  capable 
of  bearing  in  ordinary  mental  health.  Every  conceivable 
factor  of  an  exciting  or  exhausting  nature  has  at  one  time 
or  another  been  attributed  as  a  cause  of  insanity,  and  those 
only  will  be  mentioned  that  are  generally  accepted.  Stress, 
as  a  cause  of  insanity,  as  a  rule,  operates  in  an  inverse  ratio 
to  the  innate  stability  of  the  cerebral  convolutions.  A  con- 
genitally  defective  nervous  system  may  break  down  under 
the  stress  arising  from  the  physiological  demands  upon  its 
vital  energy  during  the  processes  of  growth  and  development, 
or  from  the  ordinary  incidental  circumstances  of  the  environ- 
ment, whilst  it  takes  perhaps  a  blood  poison,  some  severe 
privation,  or  a  combination  of  similar  causes  to  drive  a  person 
insane  who  is  possessed  of  a  sound  and  well-organised   brain. 

Stress,  as  applied  to  the  causation  of  insanity,  has  been 
divided  by  Mercier  into — 

(1)  Direct  stress;  ^ 

(2)  Indirect  stress. 

Direct  stress  is  that  which  affects  the   cerebral  neurons 


92  MENTAL   DISEASES 

directly  by  interference  with  their  metaboHsm  through  a 
vitiated  or  toxic  state  of  the  blood,  by  injury  to  the  brain, 
intra-cranial  haemorrhage  or  disease,  insomnia,  or  lack  of 
nutrition.  Direct  stress  affects  males  more  than  females. 
Although  many  cases  have  a  neuropathic  family  history,  it  is 
possible  for  insanity  'to  be  produced  in  a  healthy  stock  by  a 
combination  of  causes  involving  stress  of  a  direct  nature. 
Indirect  Stress  is  that  which  chiefly  operates  secondarily 
on  the  brain  convolutions  through  bodily  processes  involving 
exhaustion  of  nervous  energy,  or  by  emotional  disturbance,  as 
a  result  of  interaction  with  surrounding  circumstances.  To 
this  variety  of  stress  are  neuropaths  particularly  liable,  such 
as  that  due  to  the  physiological  epochs  of  life,  the  strain  of 
bodily  disease,  sexual  excess,  the  effect  of  a  harassing  environ- 
ment, including  the  so-called  moral  causes  of  insanity.  Stress, 
in  the  official  list  of  causes  tabulated  by  the  Commissioners,  is 
confined  to  mental  stress  only,  and  refers  largely  to  these  moral 
causes.  It  is  divided  simply  into  Sudden  Mental  Stress  and 
Prolonged  Mental  Stress  without  further  subdivision,  the 
physical  and  bodily  conditions  involving  stress  being  mentioned 
under  separate  headings.  It  need  hardly  be  emphasised  that 
mental  stress  acts  through  bodily  agencies,  and  that  mental 
and  physical  causes,  although  capable  of  differentiation,  are  at 
bottom  both  physical.  The  student  will  therefore  do  best  to 
regard  stress  as  comprising  all  agencies  affecting  the  nervous 
system,  whether  physical  or  mental. 

The  division  of  stress  into  Direct  and  Indirect,  although 
helpful  to  the  student,  is  to  some  extent  artificial,  as  som« 
causes  may  be  placed  in  either  or  both  classes.  Thus,  environ- 
mental stress  which  may  be  both  physical  and  mental  in 
origin  can  be  regarded  as  acting  directly  as  well  as  indirectly. 
Indeed,  a  history  of  either,  or  of  both,  direct  and  indirect 
stress  not  infrequently  occurs  in  many  cases  of  insanity. 

Direct  Stress.  Toxins  and  Blood  Conditions. — Poisoning 
of  the  blood  by  certain  bodies,  which  have  a  peculiar  affinity 
for  the  cortical  neurons,  constitutes  one  of  the  most  important 
elements  in  the  etiology  of  insanity.  Toxic  products  are 
frequently  the  result  of  organisms,  and  may  be  divided  into  : 
(a)  Exogenous,  or  those  introduced  from  without  the  body, 
such  as  Alcohol,  Syphilis,  etc. ;  and  (6)  Endogenous,  or  those 


GENERAL   CAUSATION  93 

generated  within  the  organism,  many  of  which,  however,  are  as 
yet  chemically  unknown.  Amongst  these  must  be  mentioned 
deleterious  substances,  the  result  of  fermenting  and  putrefying 
material  in  the  alimentary  tract,  anti-bodies  from  defect  of 
internal  secretions  (hormones),  injurious  products  from  per- 
verted bodily  metabolism,  especially  that  of  the  cortex  cerebri, 
and  the  results  of  nervous  and  muscular  fatigue. 

To  some  of  these  toxic  agencies  further  reference  must 
be  made. 

Alcohol,  etc. — Alcohol  alone  is  accountable  for  about  7|  % 
of  insanity.  The  higher  percentages  that  are  often  quoted 
represent  cases  in  which  alcoholism  is  associated  with  other 
factors,  or  where  it  is  a  symptom  of  insanity,  or  appears  in 
the  family  history  as  a  sign  of  unstable  inheritance.  An 
alcoholic  heredity  is  met  with  in  6  %  of  cases  of  each  sex.  In 
districts  where  offences  due  to  drunkenness  are  frequent,  the 
insanity  rate  is  apparently  comparatively  low.  Besides  being 
more  common  in  the  pauper  than  in  the  private  class,  alcohol 
as  a  cause  of  insanity  is  more  prevalent  in  males  than  in 
females.  Thus  the  statistics  record  alcohol  with  other  factors 
as  representing  26*3  %  of  male,  and  10' 4  %  of  female  admissions 
to  asylums. 

The  use  of  Morphia,  Cocaine,  Chloral,  Veronal  and  other 
sedatives  is  becoming  more  general  than  heretofore.  When 
they  are  taken  for  sleeplessness  or  other  conditions  for  a 
prolonged  period,  mental  disturbance  results,  especially  in 
neuropaths.  To  these  must  be  added  Atropin,  Cannabis 
Indica  and  other  drugs. 

Lead  intoxication  produces  both  acute  and  chronic  mental 
disorders.  Some  other  elements  act  similarly,  such  as  Mercury 
and  poisonous  gases  of  various  nature  (CO2,  CSg,  etc.). 

Syphilis,  both  congenital  and  acquired,  affects  the  brain  in 
many  ways,  producing  Idiocy,  Imbecility  and  various  psy- 
choses, including  General  Paralysis.  Syphilis  alone  is  answer- 
able for  2'8  %  of  Insanity,  or  associated  with  other  factors— 
12*6  %  of  males  and  1"8  %  of  females. 

Influenza  deserves  special  mention ;  for,  since  the  epidemic 
of  1890,  it  seems  to  be  a  somewhat  frequently  assigned  cause 
of  insanity  in  this  country,  viz.  3-4  %  of  males  and  3' 2  %  of 
females,  when  correlated  with  other  causes. 


94  MENTAL   DISEASES 

Fevers  and  Injections,  such  as  Scarlet  Fever,  Smallpox, 
Typhoid,  Pneumonia,  Malaria,  Septicaemia — particularly  in 
the  puerperal  state  or  from  vesical  disease — all  contribute  to 
the  causation  of  insanity. 

Other  bodily  diseases  which  may  affect  the  brain  and 
mind  through  the  circulation  are  :  Heart  and  Lung  Diseases 
which  produce  deficient  oxygenation  of  the  blood ;  Anaemias, 
primary  and  secondary;  the  poisons  of  Bright's  Disease  and 
Liver  Disease ;  the  auto-toxins  of  Dyspepsia  and  Constipation ; 
Diabetes  ;  Pellagra ;  Myxoedema ;  Cretinism  ;  and  Exophthalmic 
Goitre. 

Privation  and  Starvation — Poverty,  entailing  insufficient 
nutriment  to  the  blood,  is  an  associated  cause  of  insanity  in 
not  more  than  2i  %  of  admissions  of  either  sex. 

Insomnia  in  which  the  cortical  cells  are  by  force  of  cir- 
cumstances deprived  of  sufficient  rest  and  of  necessary  recu- 
peration must  be  allowed  as  a  factor,  yet  insomnia  is  more 
often  a  symptom  than  a  cause  of  insanity. 

Trauma,  or  injury  to  the  brain,  from  a  fall  or  blow,  with 
or  without  fracture  of  the  skull  or  laceration  of  cerebral  tissue, 
necessarily  leads  to  some  mental  affection,  but  rarely  do  such 
cases  become  inmates  of  asylums.  Injury  to  the  head,  or 
body  generally,  sometimes  lights  up  a  tendency  to  Periodic 
insanity.  Epilepsy,  and  General  Paralysis,  and  it  causes  so-called 
"  Traumatic  Neurasthenia  "  (Hysteria),  the  relationship  in 
other  cases  being  obscure  and  often  associated  with  mental 
shock.  Injuries  of  various  kinds  are  associated,  as  causes  of 
insanity,  with  other  factors  in  5  %  of  male,  and  1  %  of  female 
admissions. 

Sunstroke,  from  affection  of  the  heat  centres,  is  an  occasional 
cause  in  tropical  climates,  but  it  is  apt  to  be  overrated. 

Gross  Brain  Disease,  such  as  Tumours  of  the  brain,  Cerebral 
Haemorrhage,  Thrombosis,  Meningitis,  or  Abscess,  causes  apathy 
or  intermittent  depression  and  excitement,  but  it  does  not 
account  for  more  than  2-7  %  of  admitted  cases  of  insanity. 

Indirect  Stress.  Puberty  and  Adolescence. — The  fresh 
impressions  aroused  by  the  development  of  the  reproductive 
organs  are  liable  to  disturb  the  mental  equilibrium  of  those 
of  neurotic  stock,  or  of  children  badly  brought  up  or  spoilt. 
At  Puberty,  the  mental  states  of  the  two  sexes  tend  to  diverge. 


GENERAL   CAUSATION  95 

the  change  being  more  marked  in  girls  than  in  boys.  On  the 
other  hand,  the  stress  of  Adolescence  affects  young  men  rather 
more  than  girls,  and  weeds  out  a  considerable  number  of  cases 
with  a  bad  heritage.  They  are  associated  not  infrequently 
with  habits  of  masturbation.  The  stress  of  Puberty  and 
Adolescence,  with  other  combined  factors,  accounts  for  5  % 
of  admissions  to  asylums. 

The  Climacteric  or  Menopause. — The  change  of  life  between 
45  and  50,  with  its  ablation  of  ovarian  function,  is  apt  to 
perturb  the  nervous  system  even  of  normal  women,  and  in 
the  predisposed,  with  other  factors,  it  causes  about  8  %  of 
admissions  to  asylums.  In  men  the  gradual  decline  in  sexual 
capacity  between  55  and  60  plays  a  less  conspicuous  part. 

Senility. — This  accounts  for  a  large  number  of  cases  in 
asylums ;  in  fact,  it  stands  fourth  in  order  of  frequency  in  the 
Commissioners'  list  of  causation,  combined  with  other  factors 
accounting  for  11|  %  of  admissions.  The  brain  wastage  and 
decay  of  mental  functions  in  these  cases,  proceed  out  of  pro- 
portion to  the  deterioration  of  the  rest  of  the  body,  and  but 
rarely  has  there  been  pre -existent  insanity  earlier  in  life. 

Childbirth. — This  is  a  natural  strain  which  in  civilised 
nations  affects  women  during  pregnancy,  parturition,  and 
lactation.  Some  cases  are  also  associated  with  septic  processes, 
or  with  moral  causes  such  as  illegitimacy,  etc.  Childbirth 
alone  accounts  for  6  %  of  asylum  admissions,  but  associated 
with  other  factors  it  causes  7|  %. 

Sexual  Excess. — This  stress,  being  dependent  on  the  innate 
sexual  nature  of  the  individual,  which  varies  at  different  ages, 
is  difficult  to  estimate.  It  shows  itself  as  nervous  exhaustion, 
especially  in  the  male  sex.  It  is  sometimes  a  symptom  of 
incipient  mental  disorder. 

Celibacy  in  most  instances  cannot  be  regarded  as  harmful 
to  the  mental  functions.  The  sexual  nature  can  be  repressed 
with  safety,  provided  sufficient  vicarious  interests  are  followed 
as  outlets  for  energy  and  the  social  side  of  life  is  developed. 

Masturbation. — The  habit  of  self -abuse  is  mostly  to  be 
regarded  as  a  sign  of  nervous  instability,  and  it  may  occur  even 
in  quite  young  children.  It  causes  nervous  exhaustion  and  a 
decline  in  the  moral  nature.  The  evil  practice  is  more  common 
in  males,  especially  during  adolescence,  and  is  largely  the  result 


96  MENTAL   DISEASES 

of  imitation.  When  the  vice  affects  females,  it  betokens  a 
further  degree  of  instabihty.  It  is  a  contributory  cause  of 
insanity  in  those  with  a  marked  family  history. 

Sexual  Inversion  is  sometimes  provocative  of  Melancholia, 
but  it  is  an  anomaly,  as  a  rule,  unattended  by  pronounced  mental 
symptoms,  although  occasionally  it  is  associated  with  Paranoia, 
and  frequently  with  Moral  Degeneracy. 

Impotence,  when  congenital,  has  but  little  effect  on  the 
mental  functions  of  men,  but  if  acquired  from  sexual  excess, 
or  from  masturbation,  it  not  infrequently  leads  to  Melancholia 
with  suicidal  tendencies. 

Sterility. — The  disappointment  of  a  childless  marriage 
sometimes  occasions  unhappiness  in  women,  but  it  rarely  leads 
to  insanity.  Dyspareunia  has  been  credited  with  being  a  cause 
in  rare  instances. 

Other  Bodily  Diseases,  which  are  associated  with  insanity 
and  have  not  been  included  under  the  toxic  group  of  direct 
stresses,  are  Epilepsy  and  other  Neuroses,  Arterio-sclerosis, 
Tubercle  (1  %  of  each  sex).  Cancer  (very  rarely)  and  Local 
Disorders  which  have  an  influence  in  causing  delusions,  such 
as  Aural  Disease,  Ovarian,  Uterine,  or  Vaginal  Disease, 
Ulceration  of  Stomach  or  Bowel,  Aneurysm,  New  Growths, 
Bodily  Deformities,  etc.  Epilepsy,  with  other  factors,  is 
assigned  as  a  cause  of  insanity  in  7  %  of  male  and  5|  %  of 
female  admissions  to  asylums. 

Environmental  Stress. — Under  this  term  are  included  the  so- 
called  mental  or  moral  causes  of  insanity,  which  act  indirectly 
rather  than  directly,  chiefly  affecting  those  with  a  neuropathic 
taint.  From  25  %  to  30  %  of  insanity  can  be  attributed  to 
mental  stress  associated  with  other  causes,  especially  privation 
leading  to  nervous  exhaustion.  The  mental  stress  may  be  of 
sudden  origin,  but  more  generally  it  is  prolonged  in  nature. 
Associated  with  other  factors,  sudden  mental  stress  causes 
4  %  of  male,  and  6|  %  of  female  admissions  to  asylums,  and 
prolonged  mental  stress  21|  %  male,  and  23  %  female. 

Worry. — This  is  common  to  emotional  natures,  and  there- 
fore it  affects  women  rather  more  than  men.  In  most  cases  there 
is  a  history  of  hereditary  instability,  and  it  is  questionable 
whether  the  surrounding  circumstances  alleged  to  be  produc- 
tive of  worry  are  always  more  than  the  ordinary  incidents  of 


GENERAL   CAUSATION  97 

everyday  life  and  can  really  be  dignified  by  the  name  of  stress. 
People  who  succumb  to  worry  have  almost  always  an  unstable 
constitution,  and  the  cause,  therefore,  in  many  cases  is  in  reality 
a  symptom  of  inherent  mental  disorder. 

Business  Anxiety. — The  struggle  for  existence  does  not 
affect  women  so  much  as  men,  since  the  latter  are,  as  a  rule, 
the  breadwinners.  The  inability  to  obtain  a  livehhood,  or 
to  maintain  the  standard  of  living,  is  both  a  symptom  and 
a  cause  of  mental  disorder.  Pecuniary  losses  and  speculations 
must  be  regarded  as  factors.  It  must  be  remembered  that 
insanity  affects  the  rich  as  well  as  the  poor,  and  that  it  is 
the  change  of  circumstances  that  is  frequently  productive  of 
stress. 

Domestic  Sorrow,  such  as  family  trouble,  or  grief  at  the 
loss  of  relatives  and  friends,  affects  women  rather  more  than 
men. 

Love  Affairs  also  chiefly  affect  women,  e.  g.  disappointments 
in  love,  broken  engagements,  seduction,  desertion,  etc. 

Overwork,  as  a  cause  of  insanity,  is  rarely  due  to  muscular 
over-exertion.  It  arises  sometimes  from  uncongenial  or 
exhausting  work  without  hohdays  or  change  of  interests ;  but 
laborious  private  study  leading  to  insomnia,  or  undue  striving 
to  obtain  a  high  position,  without  regard  to  brain  capacity,  is 
a  common  cause  of  mental  breakdown. 

Occupations  such  as  involve  precarious  earnings  or  those 
devoid  of  prospects,  e.  g.  the  life  of  most  governesses,  the 
sesthetic  professions — artists,  poets,  musicians ;  retirement 
from  business  with  absence  of  hobbies,  etc. 

Faulty  Education,  such  as  excessive  stimulation  of  the 
developing  brain  without  attention  to  physical  health  and 
mental  capacity,  neglecting  to  retard  the  precocious  brain,  etc. 

Religious  Excitement  affects  emotional  natures  for  the  most 
part.  The  rehgious  element  probably  merely  adds  the  mystic 
explanation  to  the  pre-existing  tendency  to  disorder.  To  say 
that  rehgion  is  a  cause  of  insanity  is  an  exaggeration.  Church 
revivals  and  spirituahstic  seances  are,  however,  productive  of 
evil,  especially  during  the  period  of  adolescence  in  susceptible 
natures.  Rehgious  behef  of  whatever  shade  can  only  be 
beneficial  to  mental  stability,  as  its  antithesis  (Doubt  or 
Scepticism)  is  harmful  to  the  average  individual. 


98  MENTAL   DISEASES 

Solitude.— A  lonely  life  is  provocative  of  mental  disorder. 
It  is  noteworthy  that  bachelors  and  spinsters  figure  high  in 
the  statistics  of  insanity.  Abstention  from  marriage  may 
partly  be  attributed  to  innate  abnormality  or  to  absence  of 
opportunity,  but  it  is  a  fact  that  the  widowed  are  also  more 
prone  to  insanity  tha^n  the  married. 

Shock  or  Frigid. — This  is  a  sudden  mental  stress,  which 
affects  women  more  than  men,  producing  about  1  to  2  %  of 
cases  of  insanity.  It  becomes  more  frequent  in  times  of  War. 
It  is  sometimes  accompanied  by  physical  trauma,  as  in  acci- 
dents, operations,  etc. 

lynitation. — Contact  with  the  insane  very  rarely  induces 
insanity.  When  it  does  occur,  it  is  generally  in  Paranoiacs  in 
whom  mental  disorder  is  communicated  by  intimate  association, 
often  of  blood  relations. 


CHAPTER   VIII 
CLASSIFICATION 

Some  system  of  classification  of  disease  is  useful,  and 
indeed  almost  necessary,  to  the  student  in  every  department  of 
Medicine.  It  has  been  alleged  to  be  somewhat  of  a  reproach 
in  the  domain  of  Psychological  Medicine  that  classifications 
of  mental  disorders  are  so  faulty  and  so  variable.  To  some 
extent  this  is  true,  but  it  is  not  altogether  without  application 
to  other  branches  of  Medicine.  After  all,  a  classification  is  only 
a  grouping  of  diseases  as  a  help  to  diagnosis,  which  grouping 
must  change  from  time  to  time  as  our  knowledge  advances. 
It  must  be  remembered  that  under  the  generic  term  of  Insanity 
are  included  mental  disorders  which  result  from  diseases,  essen- 
tially different  from  one  another,  and  which  vary  according  to 
the  type  of  patient  affected. 

The  oldest  division  dates  back  to  Hippocrates,  and  is 
what  is  called  the  ^psychological  classification,  viz.  :  (1)  Mania ; 
(2)  Melancholia;  and  (3)  Dementia.  It  has  been  elaborated  by 
various  authors,  especially  by  Pinel,  Esquirol,  and  Greissinger. 
The  presence  of  delusions  of  a  dominant  character  in  due 
course  led  to  the  recognition  of  a  separate  class,  which  was 
first  called  Monomania,  and  afterwards  Delusional  Insanity. 
Many  writers  had  pointed  out  that  Mania  and  Melancholia 
sometimes  alternated  in  the  same  individual,  and  were  also 
accompanied  by  delusions  in  many  cases.  It  was  soon 
ascertained  that  Dementia  was  either  primary,  or  that  it  was 
secondary  to  attacks  of  Mania  and  Melancholia  or  to  other 
conditions ;  but  some  of  these  cases,  having  been  found  to 
be  congenital,  became  designated  by  the  term  "  Amentia,"  in 
contradistinction  to  Dementia,  thus  marking  off  Idiocy  and 

99 


100  MENTAL   DISEASES 

Imbecility,     Herein  lay  the  doctrine  of  the  failure  of  Evoki- 
tion,  viz.  : — 

Defect  of  involution  {i.  e.  acquisition), 
Disorder  of  mature  mental  functions,  and 
Premature  dissolution, 

which  permeates  modern  classifications. 

Later,  Dementia  of  a  recoverable  nature  was  superseded 
by  the  term  Stupor. 

The  association  of  Epilepsy  with  mental  disturbance  was 
known  in  ancient  times,  both  being  regarded  as  evidence  of 
demoniacal  possession  at  one  stage,  and  later  being  relegated 
to  a  special  group,  viz.  Epileptic  Insanity  (including  Idiocy 
and  Imbecility).  The  Epilepsy  was  considered  the  cause  of 
the  insanity,  and  not  the  effect  of  a  tertium  quid  producing 
either  conditions,  or  both  of  them. 

It  was  not  till  the  end  of  the  eighteenth  century  that  some 
cases  of  speech  and  other  muscular  defects  were  found  to  be 
associated  with  insanity.  These  cases  exhibited  a  progressive 
enfeeblement  of  mind  and  body,  ending  fatally  in  the  course 
of  two  or  three  years,  and  were  put  into  a  separate  category 
that  we  now  recognise  as  General  Paralysis.  Moral  Insanity, 
Impulsive  Insanity,  and  the  Insanity  of  the  Degenerate,  were 
first  described  by  Morel  in  the  middle  of  the  nineteenth  century. 

A  classification  on  what  was  called  physiological  grounds, 
viz.  Ideational,  Affective,  and  Instinctive,  had  been  laid  down 
by  Laycock  and  others,  whilst  one  based  on  what  is  known 
of  morbid  processes  associated  with  insanity,  i.  e.  a  strictly 
pathological  classification,  has  been  attempted  by  but  few 
authors,  and  at  present  our  knowledge  for  such  a  classification 
is  not  sufficient. 

An  etiological  classification  was  first  described  by  Skae, 
and  has  since  been  developed  by  Clouston.  It  has  the  obvious 
defect  that  the  various  causes  of  insanity  do  not  always 
produce  different  mental  disorders.  Savage  has  done  much 
to  differentiate  mental  disorders  according  to  the  different 
periods  of  life,  and  has  insisted  on  the  close  alhance  of 
psychoses  with  neuroses. 

Maudsley  and  Mercier  both  adopt  a  species  of  dual  classifi- 
cation into  :  (1)  Psychological  Forms,  or  symptoms  of  insanity, 


CLASSIFICATION  101 

e.g.  Mania,  Melancholia,  etc.;  and  (2)  Varieties  of  insanit}^, 
viz.  their  etiological  and  epochal  aspects,  e.  g.  puerperal  in- 
sanity, climacteric  insanity,  etc. ;  and  this  combination  is  at  the 
basis  of  present-day  clinical  classifications.  In  Germany  the 
schools  of  Krafft-Ebing  and  Ziehen  have  recently  been  eclipsed 
by  the  teaching  of  Kraepelin,  which  is  tending  to  dominate 
psychiatry  in  this  country  and  in  America.  To  him  we  owe 
especially  the  conception  of  Maniacal-Depressive  insanity,  and 
clearer  notions  of  Dementia  Prsecox  (including  Katatonia)  and 
of  Paranoia  or  Systematised  Delusional  Insanity.  How  far 
the  new  ideas,  promulgated  by  Freud,  concerning  the  problems 
of  sex  and  the  realm  of  the  sub-conscious  mind  are  likely  to 
influence  further  classification  remains  to  be  seen. 

For  the  Annual  Reports  of  the  English  Commissioners  in 
Lunacy  the  following  classification  promoted  by  the  Medico- 
Psychological  Association  is  now  in  use  : — 

I. — Congenital  or  Infantile  Mental  Deficiency  (Idiocy  and 
Imbecility). 
Intellectual :  (a)  with  Epilepsy ;  (6)  without  Epilepsy. 
Moral. 

II. — Insanity  occurring  later  in  life — 

Insanity  with  Epilepsy. 

General  Paralysis  of  the  Insane. 

Insanity  with  Gross  Brain  Disease. 

Acute  Delirium. 

Confusional  Insanity. 

Stupor. 

Primary  Dementia  (including  Dementia  Prsecox). 

Mania  :  Recent,  Chronic,  Recurrent      -\  ii/r     • 

Melanchoha  :    Recent,    Chronic,    Re-     ™iacal 

current  Depressive 

Alternating  Insanity  J  Insanity. 

Delusional    Insanity  :     Systematised    and    Non- 

systematised. 
Volitional  Insanity  :  Impulse,  Obsession,  Doubt. 
Moral  Insanity. 
Dementia  :  Senile,  Secondary. 

It  will  be  observed  that  the  above  classification  gives  but 


102  MENTAL  DISEASES 

little  clue  to  the  etiological  bearings  in  most  cases.  To 
assist  the  student,  most  textbooks  adopt  provisionally  a 
clinical  classification,  which  in  this  volume,  for  convenience 
of   description,  will  be  as  follows  : — 

Maniacal-Depressive  Insanity — 

Melancholia!  ,^  .        .,,      ,^ 
Mania  {(Intermittent). 

Alternating  (Periodic). 
Confusional  Insanity — 

Acute  Confusional. 

Acute  Delirium. 

Stupor. 
Paranoia  (Systematised  Delusional  Insanity). 
Amentia — 

Idiocy,  and  Imbecility. 

Congenital  Feeble-mindedness. 

Moral  Degeneracy. 
Dementia — 

Primary,  or  Dementia  Prsecox. 

Secondary,  Organic,  and  Senile. 
General  Paralysis  (Dementia  Paralytica). 
Alcoholism  and  Insanity^ — 

Morphinism  and  other  Drug  Insanities. 
Childbirth  and  Insanity. 

The  Epochs  of  Life  and  Insanity. 
Neuroses  and  Insanity — 

Epilepsy  and  Insanity. 

Hysteria  and  Insanity. 

Neurasthenia  and  Insanity. 

Psychasthenia  and  Insanity. 
General  Diseases  and  Insanity. 

Traumatism  and  Insanity. 

It  will  be  noted  that  the  first  half  of  this  list  mainly  com- 
prise forms  of  insanity,  whilst  the  remainder  are  those 
associated  with  special  clinical  varieties,  and  they  therefore  to 
some  extent  include  the  former.  It  must  also  be  stated  that 
occasionally  a  case  presents  symptoms  of  a  combined  or  mixed 
type.  This  is  analogous  to  a  combination  of  diseases  in  general 
Medicine,  which  is  almost  as  often  the  rule  as  the  exception. 


CLASSIFICATION  103 

Thus,  a  Maniacal-Depressive  individual  may  develop  Con- 
fusional  insanity,  i.  e.  Exhaustion  symptoms,  or  a  Congenital 
Imbecile  may  be  the  victim  of  Psychasthenia  or  Epilepsy ;  in 
fact,  many  insanities  are  engrafted  on  original  mental  defect. 
All  insanities  have  been  described  as  tending  to  Dementia — 
Terminal  or  Secondary  Dementia  being  the  stage  to  which  most 
of  the  incurable  invariably  gravitate. 

In  the  descriptions  of  the  different  mental  diseases  the  usual 
method  as  followed  in  the  textbooks  on  general  Medicine  is 
adopted  as  far  as  possible.  Li  the  sjntnptomatology,  however, 
a  distinction  is  made  between  mental  and  physical  sj^mptoms, 
which  is  to  some  extent  artificial.  It  must  be  borne  in  mind 
that  the  view  is  taken  that  mental  s}Tnptoms  are  always 
associated  with,  or  dependent  on,  nervous  or  bodily  conditions, 
but  that  it  is  necessar}^  to  pay  more  attention  to  such  symptoms 
than  is  customary  in  the  examination  of  an  ordinary  medical 
case. 

Li  general  hospitals  the  student  has  been  accustomed  to 
find  the  departments  divided,  according  to  sex,  into  medical, 
surgical,  ophthalmic,  gjnecological  and  other  wards.  In 
public  asylums — or  hospitals  for  the  insane,  as  they  should  be 
called — besides  making  special  provision  for  private  patients  as 
a  rule,  the  insane  of  either  sex  are  classified  according  to  the 
wards  for  which  they  appear  most  suited,  viz.  according  to 
the  amount  of  supervision  thought  to  be  necessary,  and  the 
accommodation  that  is  available. 

The  most  important  consideration  is  to  ascertain  whether 
a  case  is  incurable  or  curable — e.  g.  G.P.  or  not  G.P.,  whether 
acute  or  chronic,  suicidal  or  dangerous.  It  must  be  remem- 
bered, however,  that  a  recent  or  acute  case  may  be  but  a 
recurrence  of  a  former  attack,  or  it  may  exhibit  the  elements 
of  incurabihty  from  the  outset,  and  that  a  chronic  case  is 
sometimes  subject  to  acute  exacerbations. 

It  will  be  found  that  there  is  generally  a  separate  block 
of  a  special  ward  for  newly  admitted  cases  where  they  are 
kept  in  bed  for  observation  and  close  medical  examination. 
These  are  then  drafted  off  into  other  wards,  w^hen  the 
diagnosis  is  complete.  There  are  again  special  wards  for 
Suicidal  cases,  and  for  General  Paral;)i;ics  who  require  watch- 
ing, others  for  Epileptics,  where  the  proportion  of  attendants 


104  MENTAL   DISEASES 

is  relatively  high.  Old  or  feeble  patients  and  dements  are 
usually  kept  separate  from  violent  patients,  and  those  that 
are  noisy  at  night,  as  a  rule,  sleep  in  detached  single  rooms. 
Chronic  patients  capable  of  doing  a  certain  amount  of  work, 
and  convalescents  from  acute  attacks,  are  in  wards  where 
more  liberty  is  allowed.  Lastly,  there  is  an  Infirmary  ward 
for  each  sex,  where  patients  are  mostly  confmed  to  bed,  and 
detached  blocks  for  cases  of  infectious  disease,  including 
Ulcerative  Colitis  and  Phthisis. 


CHAPTER   IX 
MELANCHOLIA 

Maniacal-Depressive  Insanity  is  the  term  introduced 
by  Kraepelin ;  in  this  category  may  be  grouped  nearly  half 
the  number  of  cases  which  are  admitted  to  our  asylums. 
Amongst  these  are  included  the  cases  of  Intermittent  Melan- 
cholia and  Mania,  at  all  ages,  in  which  no  adequate  etiology 
can  be  assigned  beyond  the  fact  of  mental  instability.  Some 
recover,  never  to  break  down  again,  whilst  others  recur  at 
increasingly  shorter  intervals,  and  a  large  proportion  end  in 
Secondary  Dementia.  To  a  small  but  special  subclass  belong 
the  cases  of  Alternating,  Circular,  or  Periodic  insanity,  in 
which  the  recurrence  is  regular  and  more  intractable,  although 
the  tendency  to  Dementia  is  not  so  marked.  Various  writers 
use  the  term  Melancholia  for  all  states  of  depression  which 
accompany  different  diseases  whether  associated  with  insanity 
or  not.  It  is  best,  however,  to  restrict  it  to  those  cases  of 
Intermittent  depression  which  are  frequently  called  Idiopathic. 
It  is  also  a  phase  of  Alternating  Insanity  which  is  described 
later. 

Melancholia  may  be  defined  as  a  state  of  mental  pain.  The 
ordinary  feeling  of  discomfort  and  misery,  which  afflicts  some 
mortals  from  time  to  time,  and  which  is  characterised  as  "  a 
fit  of  the  blues,"  is  a  state  of  melancholy  which  does  not  pass 
the  border-line  of  the  pathological  state  we  commonly  call 
Melancholia.  By  Melancholia  we  mean  an  intense  feeling 
of  depression  and  misery,  such  as  the  physical  condition  of  the 
patient  does  not  warrant,  and  which  has  no  proper  relationship 
to  the  external  circumstances  of  the  patient. 

Etiology. — Although  there  is  as  yet  no  convincing  demon- 
stration of  the  nature  of  the  toxins  in  this  disease,  their 
existence  can  hardly  be  denied.     Some  authorities,  from  the 

105 


106 


MENTAL   DISEASES 


close  association  of  dyspepsia  and  constipation  with  this  dis- 
order, consider  that  the  toxins  derive  their  origin  from  the 
intestinal  tract,  and  affect  the  nervous  centres  through 
the  circulation.  It  is,  however,  much  more  probable  that  the 
poisons  arise  from  defective  metabolism  in  the  cortex  itself, 
whereby  certain  products  are  not  properly  eliminated ;  and  thus 
there  results  a  paralysing  effect  on  the  cortical  neurons,  pro- 
ducing a  state  of  inertia  and  mental  pain.     As  exciting  causes, 

the  ordinary  stresses  of  life  are 
sufficient  to  develop  an  attack. 
Physical  Signs. — The 
patient  looks  ill,  and  commonly 
loses  weight.  All  the  secretions 
tend  to  be  diminished,  the  skin 
is  dry,  as  is  also  the  hair,  which 
is  an  index  of  the  want  of  general 
nutrition,  and  the  nails  are 
brittle .  The  temperature  is  sub- 
normal. The  blood  becomes 
chlorotic.  The  pulse  frequency 
is  increased,  and  there  is  a 
tendency  to  high  tension.  The 
cardiac  systole  is  diminished 
in  force,  and  the  hands  and  feet 
are  apt  to  be  cold.  Respiration 
is  shallow  and  at  times  lung 
complications  ensue.  The  tongue 
is  dry  and  furred ;  there  is 
invariably  dyspepsia  with  loss 
of  appetite,  and  frequently  a  foul  odour  from  the  breath. 
An  examination  of  the  gastric  juice  shows  an  increase  of 
hydrochloric  acid,  and  its  peptonising  power  is  reduced. 
The  action  of  the  liver  is  sluggish,  and  constipation  is  the  rule. 
When  diarrhoea  exists,  it  is  generally  associated  with  hardened 
faecal  lumps.  The  muscular  tone  of  the  intestines  is  weak,  and 
there  is  a  diminution  of  the  alimentary  secretions.  The  urine 
varies  in  quantity  according  to  the  amount  of  fluid  imbibed, 
but  is  usually  less  than  normal.  The  phosphates  and  urates 
are  increased,  and  indoxyl  is  frequently  present.  The  sexual 
function  is  in  abeyance.     Menstruation  is  scanty  or  absent. 


Fig.  20.^ 


melancholia. 


MELANCHOLIA  107 

The  expression  is  one  of  abject  misery.  The  forehead  is 
wrinkled,  and  the  corners  of  the  mouth  incline  downwards. 
Sobbing  may  occur,  but  lachrjnuation  is  rare.  The  attitude 
of  the  patient  is  a  stooping  one,  with  some  rigidity  of  the 
shoulder  and  hip-joints,  resembling  a  slight  double  hemiplegia 
as  suggested  by  Stoddart.  The  smaller  peripheral  joints 
exhibit  restless  movements  in  the  agitated  cases.  The  gait 
is  usualty  slow  and  is  accompanied  by  effort.  The  tone  of 
voice  frequently  undergoes  change,  and  reaction  to  questions 
is  slow.  The  writing  is  similarly  affected,  being  generally 
small  and  accomplished  slowly  and  \\dth  difficulty.  The  deep 
reflexes  are  sometimes  increased. 

Mental  Symptoms. — Sensation  and  Perception  are  normal 
in  cases  of  pure  Melancholia,  but  in  chronic  cases  aural  hallu- 
cinations are  apt  to  occur.  There  should  be  no  anaesthesia 
or  disorientation  in  uncomplicated  cases.  Attention,  both 
voluntary  and  instinctive,  is  defective.  Memory  is  for  the 
most  part  unimpaired.  There  is  retardation  and  difficulty 
in  the  association  of  ideas,  and  the  intellectual  life  is  pervaded 
by  painful  emotions.  Sorrow  and  sadness  pursue  the  patient 
in  his  waking  hours;  and  during  his  snatches  of  sleep  he  is 
disturbed  by 'disagreeable  dreams.  He  is  plagued  by  morbid 
apprehensions,  and  is  haunted  by  a  feeling  of  inefficiency, 
and  inabihty  to  cope  with  difficulties  real  or  imaginary.  There 
is  a  sense  of  resistance  in  the  environment  which  the  patient 
has  not  experienced  before.  His  present  life  is  scarcely  bear- 
able, and  the  future  seems  impossible.  The  patient  is  harassed 
by  a  feeling  of  impending  evil  which  is  at  first  vague  and  in- 
definable. As  the  disturbance  of  the  neuronic  association  in- 
creases, disorder  of  the  sequence  of  ideas  ensues,  and  delusions 
arise  as  a  result  of  this  dissociation.  These  tend  to  offer  some 
explanation  of  the  patient's  morbid  state.  He  imagines  that 
he  has  committed  some  unpardonable  sin,  that  he  is  forsaken  by 
God,  that  he  has  committed  a  crime,  that  he  is  a  disreputable 
mortal,  or  that  he  has  lost  his  money  and  ruined  his  family. 
Should  he  suffer  from  hallucinations  also,  these  tend  to 
accentuate  his  morbid  ideas,  and  he  hears  a  "  voice  "  accusing 
him  accordingly.  He  withdraws  himself  more  and  more 
from  his  fellow  creatures.  This  growth  of  morbid  egoism 
prevents  him  from  taking  any  interest  in  his  family  or  in  others, 


108  MENTAL   DISEASES 

and  he  is  apathetic  to  his  surroundings  or  else  he  has  a  distinct 
aversion  to  them. 

The  primary  instincts  tend  to  become  paralysed  or  per- 
verted. There  is  no  healthy  desire  for  exercise  or  recreation. 
The  patient  loses  all  appetite  for  food,  and  in  bad  cases  there 
is  absolute  refusal  of  nourishment.  The  persistent  refusal  of 
food  is  usually  accompanied  by  some  delusion,  and  occasionally 
by  hallucinations  or  illusions.  Thus  the  patient  may  believe 
that  his  throat  is  blocked  up,  and  that  accordingly  he  cannot 
swallow ;  or  that  his  bowels  never  act,  and  that  everything  he 
takes  decomposes  within  him ;  or  that  his  food  is  poisoned,  or  he 
may  state  that  a  "  voice  "  tells  him  not  to  eat.  In  some  cases 
the  organs  of  taste  and  smell  are  affected,  The  normal  desire 
to  live  may  likewise  disappear,  and  the  patient  may  attempt 
to  make  away  with  himself.  Ideas  indicating  suicidal  intention 
are  frequently  expressed,  but  the  act  is  sometimes  committed 
without  any  warning,  especially  in  the  early  days  of  the  dis- 
order, before  the  patient  is  placed  under  care.  Refusal  of  food 
and  attempts  at  suicide  are  conditions  which  render  every 
Melancholiac  an  anxious  case.  Although  the  self -conservative 
instincts  are  weakened,  there  is  fortunately  not  infrequently  a 
loss  of  will-power  and  lack  of  self-confidence,  which  prevent 
many  of  these  patients  from  taking  their  lives. 

Another  symptom  of  extreme  importance  in  Melancholia 
is  insomnia,  Night  after  night,  unless  the  patient  is  treated, 
he  is  wretched  and  sleepless.  He  is  haunted  by  depressing 
ideas  and  he  reflects  upon  them.  He  paces  about  the  room  in 
his  miserable  and  restless  state,  and  perhaps  obtains  but  one 
or  two  hours  of  quietude  towards  morning;  he  arises  again 
unrefreshed,  and  is  tormented  by  his  feelings  of  utter  wretched- 
ness and  misery. 

Clinical  Varieties. — Melancholia  is  said  to  be  Acute  or 
Recent  when  the  onset  is  intense,  or  when  it  has  originated 
within  twelve  months ;  Chronic  when  it  persists,  and  the 
chances  of  recovery  are  less  certain ;  and  Recurrent  when 
there  have  been  previous  attacks.  The  subdivisions  that  may 
be  described  are — 

(a)  Simple  Melancholia. 
(&)  Delusional  Melancholia. 


MELANCHOLIA 


109 


o 


110  MENTAL  DISEASES 

(c)  Hypochondriacal  Melancholia. 

(d)  Resistive  Melancholia. 

(e)  Agitated  Melancholia. 
(/)   Stuporous  Melancholia. 

Simple  Melancholia  consists  in  mental  depression,  which 
is  more  than  a  passing  fit  of  low  spirits,  and  is  in  no  adequate 
proportion  to  the  circumstances  and  bodily  health  of  the 
patient.  The  patient  is  fully  aware  of  his  state  and  there  is 
no  intellectual  flaw.  He  is  sleepless  and  restless,  he  can  only 
give  his  attention  to  any  occupation  with  a  sense  of  effort, 
and  he  is  often  a  potential  suicide. 

Delusional  Melancholia  is  characterised  by  the  presence 
of  delusions  which  have,  as  it  were,  crystallised  out  by  dis- 
sociation, and  which  serve  as  an  explanation  to  the  patient  of 
his  depression.  The  delusions  frequently,  therefore,  arise  as  a 
further  state  of  dissolution  in  Simple  Melancholia  ;  the  patient 
reproaches  himself  with  some  crime  or  moral  offence  in  the 
past,  or  his  ideas  affect  his  religious  convictions  and  he  imagines 
he  is  eternally  damned. 

Hypochondriacal  Melancholia. — This  term  is  applied 
to  those  cases  in  which  the  delusions  relate  to  the  health  and 
bodily  organs  of  the  patient.  Some  patients  say  that  their 
brains  have  been  destroyed,  or  that  their  sexual  organs  are 
ruined,  resulting  in  impotence.  The  majority,  however,  have 
delusions  concerning  the  alimentary  tract,  that  the  throat  is 
blocked  up  or  that  the  bowels  are  obstructed.  These  cases  are 
exaggerations  of  those  Hypochondriacs  met  with  in  general 
practice,  and  tax  the  patience  of  every  practitioner.  They 
have  to  be  differentiated  from  cases  of  Hypochondriacal 
Paranoia,  in  which  the  patient  attributes  his  ill-health  to  the 
evil  machinations  of  others. 

Resistive  Melancholia. — This  special  term  covers  a 
good  many  delusional  cases  in  which  there  is  active  resistance 
to  whatever  is  done  for  them.  Resistance  is  shown  in  feeding 
and  dressing,  or  in  any  movements.  This  group  has  to  be 
distinguished  from  the  Katatonic  variety  of  Dementia  Prsecox. 

Agitated  Melancholia. — Under  this  heading  are  in- 
cluded the  restless  Melancholiacs  who  pace  up  and  down  in  an 
aimless  manner,  wringing  their  hands  as  a  vent  to  their  pent-up 


MELANCHOLIA  111 

misery.  If  it  were  not  for  their  abject  depression,  the  excite- 
ment that  they  exhibit,  ahnost  places  them  within  the  categor}^ 
of  Mania. 

Stuporous  Melancholia. — This  is  also  called.  Melancholia 
Attonita.  The  patient  scarcely  ever  speaks  or  moves,  but 
stands  in  a  rigid  condition,  or  sits  in  a  bent  position  character- 
istic of  a  severe  degree  of  Melancholia. 

Course. — ^An  attack  of  Melancholia  usually  begins  gradu- 
ally, reaching  its  acme  during  the  first  month;  signs  of  im- 
provement are  noticeable  in  another  month  or  two,  and  the 
patient  slowly  recovers  in  five  to  six  months.  Sudden  re- 
coveries are  not  to  be  looked  for,  and  when  they  do  occur, 
they  not  infrequently  lead  to  an  early  relapse.  As  the  patient 
improves  he  obtains  more  natural  sleep,  his  appetite  is  better, 
the  bowels  move  properly,  the  characteristic  attitude  disappears 
and  he  becomes  more  active.  His  countenance  loses  its  care- 
worn expression  and  the  complexion  becomes  clear.  If  the 
patient  improves  physically  without  corresponding  mental 
im.provement,  the  case  is  probably  becoming  chronic. 

Diagnosis. — Melancholia  has  to  be  distinguished  from  the 
following  disorders :  from  the  depressed  type  of  General  Paralysis 
by  tremors,  slurring  of  speech,  and  Argyll-Robertson  pupil; 
in  doubtful  cases,  lumbar  pmicture  might  be  resorted  to.  Some 
cases  of  Dementia  Prsecox  begin  with  depression,  which  is, 
however,  followed  by  mannerisms  and  weak-mindedness,  and 
"  voices  "  are  more  common.  In  Confusional  insanity,  the 
emotional  element  is  not  so  pronounced,  hallucinations  and 
sensory  disturbance,  including  anaesthesia,  are  usual,  and 
disorientation  takes  place.  In  Neurasthenia  and  Psychasthenia, 
insight  is  not  lost,  and  sensations  and  fears  prevail.  The  history 
of  a  fit  usually  points  to  General  Paralysis  or  Epilepsy. 

Prognosis. — This  is  usually  favourable  if  the  patient  is 
promptly  placed  under  treatment,  and  it  is  better  in  early  than 
in  late  life.  Exhaustion  symptoms,  as  well  as  previous  attacks, 
detract  from  a  good  prognosis,  as  does  also  prolongation  of 
the  existing  attack  for  more  than  a  year.  Fully  50  %  recover, 
but  of  this  percentage  a  certain  proportion  recur,  or  alternate 
with  a  state  of  Mania.  About  20  %  of  cases  become  chronic, 
and  most  of  these  in  time  drift  into  Dementia,  whilst  5  %  of 
the  cases  die  of  exhaustion,  lung  affections,  or  other  intercurrent 


112  MENTAL   DISEASES 

maladies.  On  rare  occasions  it  happens  that  a  patient  who 
has  suffered  from  Melanchoha  for  many  years  is  discharged 
from  an  asylum  recovered.  The  Maniacal-Depressive  psychosis 
manifested  by  the  mild  depression  accompanying  digestive 
and  other  bodily  disturbances  has  a  most  satisfactory 
prognosis. 

Pathology. — As  has  been  already  stated,  positive  evidence 
of  the  existence  of  toxins  affecting  the  cortex  cerebri  is  still 
wanting.  Defective  neuronic  metabolism  offers  the  best 
explanation  of  the  disease,  and  when  advances  in  biochemical 
methods  occur  further  light  will  probably  be  forthcoming. 
Craig  attributes  the  feeling  of  depression  as  due  to  the  excessive 
blood-pressure  which  is  nearly  always  present.  Post-mortem 
examination  and  microscopic  anatomy  have  not  revealed 
anything  of  importance,  either  as  regards  the  cortical  nerve 
cells,  the  cerebro-spinal  fluid,  or  the  blood ;  whilst  the  visceral 
changes  must  be  regarded  for  the  most  part  as  secondary. 

Treatment. — ^Rest,  appropriate  dieting,  medicinal  treat- 
ment, and  fresh  air,  will  do  wonders  in  the  majority  of  cases 
that  are  attended  to  early.  Psychological  conversations  do 
some  good  in  certain  cases,  but  too  much  must  not  be  expected 
from  this  line  of  treatment  or  from  psycho-analysis,  looking 
at  the  probable  pathology  of  the  disorder.  The  relations 
will  already  have  done  harm  by  talking  to,  and  irritating  the 
patient,  imploring  him  to  rouse  himself  from  his  depressed 
state.  Such  counsel  usually  emphasises  the  ideas  and  feelings 
of  utter  despair  that  already  torment  him.  He  would  of 
course  try  to  shake  off  the  condition  if  he  could.  Doubtless 
he  has  been  made  to  go  about  sight-seeing,  to  visit  picture 
galleries  or  to  travel,  in  the  hope  of  distracting  his  thoughts. 
Experience  has  abundantly  proved  that  such  methods  of 
treatment  are  not  only  of  no  avail,  but  are  positively  harmful, 
at  the  outset  of  an  attack  of  Melancholia.  To  store  up  the 
patient's  energy  by  rest  is  the  safest  measure  to  adopt.  This 
is  best  carried  out  in  bed,  with  the  services  of  skilled  mental 
nurses.  If  the  patient  is  too  restless  to  remain  in  bed,  he  may 
in  some  cases  be  managed  better  in  a  lounge  chair,  in  his  room 
or  in  the  open  air ;  but  exercise  must  at  all  cost  be  limited.  To 
prescribe  travel  for  an  early  case  of  well-defined  Melancholia 
is  to  hazard  its  recovery,  whilst  the  risks  of  suicide  are  not  to 


MELANCHOLIA  113 

be  lost  sight  of.     Whether  the  patient  is  best  treated  at  home 
or  not,  depends  on  circumstances  which  are  dealt  with  in  the 
Chapter   on   General  Treatment ;   so   also   is  the   question  of 
certification.     The  visits  of  relations  should  be  as  infrequent 
as   possible.      The    first    consideration   is   to   investigate   the 
physical  health  of  the  patient.     A  record  of  the  bodily  weight 
must  be  carefully  kept.     The  appetite  and  digestive  functions 
will  require  close  attention,  and  the  habitual  constipation  must 
be  relieved,     For  this  purpose,  Epsom  salts  or  mineral  waters 
in  the  morning  should  be  given,  with  an  occasional  Aloin  pill 
or  dose  of  Cascara  or  other  laxative  at  night.     Enemata  are 
frequently  necessary,  and  in  some  cases  abdominal  massage 
is  efficacious.     A  stomachic  mixture  is  also  very  serviceable 
to   some  patients ;    any  diathesis  or  constitutional  affection 
must  be  treated  on  its  own  special  lines,  e.  g.  Anaemia,  Gout,  etc. 
As  to  diet,  the  patient  is  probably  reduced  in  weight,  and 
he  must  be  nourished  so  that  he  may  show  a  weekly  increase 
in  weight.     The  tendency  to  insufficient  secretions   must    be 
counteracted  by  administering  food  in  liquid  form.     The  usual 
routine  is  to  let  the  patient  have  as  much  ordinary  diet  as  his 
digestive  organs  will  admit,  and  to  give  at  least  three  pints  of 
milk  in  addition.    The  fluid  will  assist  the  eliminatory  organs 
in  ridding  the  patient  of  toxic  products.     A  good  deal  can  be 
done  by  tactful  nurses  in  getting  the  patient  to  take  sufficient 
nourishment,  but  in  many  cases  absolute  refusal  of  food  takes 
place.     At  times  this  may  be  overcome  by  spoon  feeding,  but 
as  a  rule  the  best  plan  is  to  have  recourse  to  the  nasal  or 
oesophageal  tube  forthwith,  as  described  elsewhere  {vide  p.  301), 
To  help  the  nutrition,  massage  may  be  used.     Stimulants  are 
best  withheld,  unless  the  patient  is  old  or  in  an  enfeebled  state. 
A  glass  of  wine  is,  however,  useful  with  the  meals  in  some 
patients  as  they  begin  to  convalesce.     To  prevent  attempts 
at  suicide,  the  patient  must  be  kept  under  constant  observation 
by  night  as  well  as  by  day.     He  should  be  searched,  and  all 
dangerous  implements,  such  as  knives  and  scissors,  must  be 
removed,  or  be  left  in  the  charge  of  nurses.     Even  a  hand- 
kerchief, or  the  girdle  of  pyjamas,  should  be  handed  over  in 
certain  cases.     The  danger  of  precipitation  from  the  window 
or  over  banisteis  must  be  guarded  against.     Keys  and  bolts 
should  be  removed,  especially  from  the  w.-c,     A  determinedly 


114  MENTAL   DISEASES 

suicidal  patient  should  always  be  sent  to  an  asylum.  As  the 
attack  subsides,  and  the  patient  begins  to  improve,  a  time  will 
come  when  the  continuous  observation  maj  be  relaxed,  the 
responsibility  for  which  rests  with  the  medical  attendant. 

Insomnia  demands  the  most  prompt  and  energetic  treat- 
ment, especially  at  the  commencement  of  the  illness.  Absolute 
quiet  must  be  procured,  in  a  property  ventilated  room.  The 
bed-clothing  should  be  appropriate  and  the  feet  warmed,  if 
necessary  by  means  of  hot  bottles.  Nourishment  during  the 
night  should  be  given  if  the  patient  is  wakeful.  If  ordinary 
means  fail  to  produce  sleep,  a  sedative  .should  be  administered. 
Paraldehyde,  in  doses  of  3j  to  qu],  given  at  night-time  mth 
peppermint  or  quillaia  produces  healthy  repose ;  but  it  has 
mifortunatelj^  a  nasty  odour  which  it  is  difficult  to  disguise. 
It  also  makes  some  patients  disinclined  to  take  their  food. 
The  Bromides  in  3^8  doses  are  often  helpful  with  or  -with- 
out gr.  X  to  XXX  of  Chloral.  Veronal,  Sulphonal,  or  Trional 
should  be  restricted  to  Agitated  and  to  Senile  cases.  Opiates 
are  not  to  be  recommended  as  a  rule,  but  a  solution  of  Mor- 
phia in  small  doses — Liquor  Morphinae  Bimeconatis — n[xv 
given  three  times  a  day  suits  some  patients  admirably. 
During  the  daj^time  the  patient  should  be  allowed  to  read 
newspapers  or  light  literature  if  so  inclined,  but  no  occupation 
should  be  forced  upon  him.  A^Tien  he  begins  to  convalesce, 
he  should  be  allowed  to  take  exercise  sparing^  at  first,  and 
he  should  not  be  allowed  to  do  any  work  for  some  months. 
Should,  unfortunately,  mental  recovery  not  ensue  with  the 
bodily  improvement,  a  course  of  Th3'roid  Extract  should  be 
given  (vide  p.  310)  before  the  case  be  given  up  as  chronic. 


MANIA 

The  term  Mania  is  now  generalty  reserved  for  the  excite- 
ment of  the  Intermittent  tj'^pe  of  Maniacal-Depressive  insanity. 
The  excitement  is  commonly  accompanied  by  exaltation  or  a 
sense  of  well-being,  which  is  out  of  harmonj-  with  the  surround- 
ing circumstances  of  the  patient.  The  disorder  either  ends  in 
recover}",  complete  or  partial,  or  when  prolonged  and  severe., 
it  may  terminate  in  Dementia.     A  small  proportion  of  cases 


MANIA  115 

die  from  exhaustion.  As  with  Melancholia,  it  is  also  a  phase 
or  part-process  of  Alternating,  Circular,  or  Periodic  Insanity. 

Etiology. — ^Most  authorities  agree  that  toxins  are,  at 
bottom,  the  cause  of  an  attack  of  so-called  Idiopathic  Mania. 
Also  that  such  toxins  are  probably  produced  locally,  as  a 
result  of  irregular  metabolism  in  the  convolutional  areas. 
They  must  differ  in  composition  or  degree  from  the  toxins  of 
Melancholia,  as  their  effects  are  entirely  different.  Bevan 
Lewis  regards  Mania  as  a  further  state  of  mental  reduction 
than  is  Melancholia  from  the  evolutionary  point  of  view. 

Hereditary  influence  is  usually  a  predisposing  factor,  and 
the  exciting  causes  are  often  such  that  should  not  upset  a 
properly  balanced  mental  constitution. 

Physical  Signs. — These  vary  according  to  the  acuteness 
of  the  attack.  The  eyes,  facial  expression,  and  restlessness 
indicate  excitement,  and  the  general  appearance  of  the 
patient  is  untidy.  In  the  milder  cases,  there  is  not  much 
bodily  disorder,  whilst  in  some  cases  the  patient  looks  very  ill 
and  rapidly  loses  weight.  As  in  Melancholia,  the  patient 
becomes  ansemic,  and  there  is  gastro-intestinal  disturbance 
with  hyperacidity  of  the  gastric  juice.  The  tongue  is  furred, 
and  the  appetite  is  capricious,  sometimes  the  patient  eats 
voraciously  and  then  refuses  all  nourishment  for  a  time .  The 
bowels  are  variable,  and  often  constipation  is  present  and 
requires  attention.  The  skin  is  moist,  and  there  is  a  peculiar 
mousy  odour  of  the  sweat  secretion.  Patients  tend  to  strip 
themselves  of  clothing,  especially  at  night.  The  temperature 
is  unaffected.  The  urine  is  generally  normal,  but  is  slightly 
in  excess.  The  usual  menstrual  flow  in  women  is  irregular — 
sometimes  being  absent,  and  at  other  times  excessive.  The 
mental  excitement  is  usually  increased  during  the  catamenia. 
The  pulse  rate  is  accelerated,  but  there  is  not  a  proportionate 
increase  in  respiration. 

The  superficial  reflexes  are  brisk  and  the  deep  reflexes  are 
variable.  In  contradistinction  to  Melancholia,  there  is  no 
rigidity  but  there  is  muscular  hyperactivity.  The  patient 
is  always  on  the  move,  and  it  is  to  be  noted  that  the  move- 
ments are  mostly  in  connection  with  the  large  proximal  joints. 
Stoddart  has  especially  pointed  this  out  as  regards  the  hand- 
shake of  the  Maniac,  which  is  frequently  just  a  swing  from  the 


116  MENTAL   DISEASES 

shoulder,  whereas  the  Melancholiac  moves  his  hand  slowly  from 
the  wrist. 

Mental  Symptoms. — In  uncomplicated  cases  there  is  no 
anaesthesia,  but  this  occurs  if  Exhaustion  or  Stupor  super- 
venes. During  the  height  of  the  attack  there  is  not  uncom- 
monly hyperasthesia  of  the  senses.     This,  to  some  extent, 


Fig.  22. — Acute  mania. 

explains  the  desire  to  remove  the  clothing.     Hearing  is  also 
hj^peracute. 

Perception  and  Orientation  may  be  normal,  but  the  former 
is  generally  hyperactive,  and  reaction  is  brisk.  Hallucinations 
and  illusions,  when  present,  are  due  to  complications.  The 
association  of  ideas  in  Mania  is  alwaj^s  active,  uideed  it  would 
seem  as  if  the  patient's  thoughts  are  too  rapid  to  express. 
There  is  truly  a  "  flight  of  ideas  "  in  many  cases,  and  the 
acceleration  of  ideas  is  such  that  the  connecting  links  in  the 


MANIA  117 

reasoning  process  are  missing.  Thus  there  occurs  a  state  of 
incoherence.  The  ordinary  paths  of  association  are  not  in 
proper  use ;  there  is  a  condition  of  short  circuiting  to  lower 
levels.  The  writing  is  large,  untidy,  and  exhibits  incoherence, 
similar  to  that  of  the  patient's  speech.  He  may  have  a 
certain  amount  of  insight  into  his  state,  but  the  exaggerated 
sense  of  well-being,  the  result  of  internal  stimulation,  may  be 
accompanied  by  sufficient  neuronic  disturbance  to  lead  to  the 
formation  of  delusions.  These  delusions  are  usually  of  a  fleet- 
ing character.  The  patient  imagines  he  is  possessed  of  much 
strength  or  wealth,  or  that  he  is  a  person  of  distinction  and 
of  title.  The  concentration  of  energy  into  the  muscular  area 
does  indeed  give  an  artificial  increase  of  power  to  the  Maniac, 
and  a  patient  has  been  able  to  execute  a  feat  in  a  state  of 
excitement  which  he  could  not  perform  in  his  normal  condition. 
The  welling-up  of  energy  is  not  confined  to  the  voluntary  mus- 
cular system  only,  but  pervades  the  abdominal  viscera  also. 
The  incoming  stimuli  from  the  viscera  lead  to  disordered 
emotions,  which  the  patient  is  unable  to  control.  He  becomes 
passionate  and  violent,  with  little  or  no  provocation.  He 
laughs  at  one  time  and  cries  at  another.  He  loses  his  higher 
sentiments  and  sense  of  propriety,  and  becomes  abusive  and 
destructive.  Bjs  instincts  become  disordered  or  perverted. 
He  tosses  his  food  about,  tears  his  clothing  and  bedding,  and 
in  bad  cases  loses  all  sense  of  cleanliness.  The  sexual  desire 
is  increased  and  becomes  micontroUed,  so  that  the  patient 
loses  all  ideas  of  modesty  and  becomes  erotic,  and  may  give 
way  to  fits  of  self -abuse.  In  women  this  is  more  common 
during  menstruation .  The  patient 's  will-power,  which  to  him  is 
enhanced,  is  really  weakened,  so  that  he  can  give  no  sustained 
attention  to  any  subject.  Every  idea  tends  to  expend  itself 
in  immediate  action.  The  patient  becomes  impulsive  from 
failure  of  inhibition  and  loss  of  self-control.  Any  chance 
stimulus  diverts  his  ideational  life.  Thus,  examples  of  insane 
rhyming  and  punning  are  exhibited  which  would  be  impossible 
to  the  patient  when  well.  This  state  of  excitement  and  exal- 
tation leads  to  boastfuhiess  or  bragging  and  extends  itself 
in  every  available  direction. 

Unless  controlled,  the  patient  would  spend  all  his  money 
and  overdraw  his  banking  account.     His  social  and  altruistic 


118  MENTAL  DISEASES 

feelings  are  quite  benumbed,  and  he  disregards  the  admoni- 
tions of  his  family.  He  sleeps  but  little,  wakes  early  in  the 
morning,  and  is  on  the  move  again,  with  a  press  of  activity 
and  incessant  talk.  Noisy  and  indifferent  to  the  feelings  of 
others,  he  is  a  menace  to  the  peace  of  the  household,  and 
becomes  violent  if  interfered  with.  The  memory  is  usually 
quite  unaffected,  and  on  recovery  the  patient  may  recapitulate 
the  whole  course  of  his  disorder.  After  a  severe  Maniacal 
outburst,  the  patient  is  liable  to  an  attack  of  Stupor.  This 
condition,  which  is  described  later,  implies  a  reversal  of  the 
signs  and  symptoms  of  Mania  and  may  last  some  weeks 
before  recovery  ensues. 

Clinical  Varieties. — In  Mania,  the  distinctions  usually 
made,  are  :  (a)  Simple;  (6)  Acute  or  Recent;  (c)  Chronic; 
and  (d)  Recurrent,  Acute  Delirious  Mania  (or  Acute 
Delirium),  which  by  some  authorities  is  included  under  this 
heading,  is  described  by  the  writer  separately ;  its  sympto- 
matolog}^  resembles  more  closely  the  Confusional  and  Exhaus- 
tion msanities  than  Maniacal-Depressive  insanity. 

Simple  Mania. — This  is  a  state  of  mild  exaltation,  with  an 
exaggerated  feeling  of  self-importance.  The  patient  is  over- 
confident of  his  powers  and  capabilities.  He  is  boastful  and 
resents  all  interference.  He  is  sleepless,  and  believes  two  or 
three  hours'  sleep  at  night  is  sufficient  for  him.  He  therefore 
gets  up  early,  and  busies  himself  with  other  people's  affairs 
as  well  as  his  own.  He  is  talkative,  irritable,  and  restless; 
and  he  is  inclined  to  run  into  extravagance  and  excesses  in  all 
directions.  He  dresses  himself  up  and  makes  overtures  to  the 
opposite  sex,  and  frequently  takes  more  alcohol  than  is  good 
for  him.  His  memory  is  unaffected.  He  is  more  of  an  exag- 
geration than  a  perversion  of  his  normal  self.  The  condition 
is  mostly  seen  during  the  period  of  adolescence,  and  it  is 
often  difficult  to  certify  the  patient  or  place  him  under  any 
form  of  control.     It  is  sometimes  known  as  Hypomania. 

Acute  Mania. — ^This  occurs  with  the  severest  degree  of 
excitement  and  loss  of  self-control,  and  the  physical  signs 
are  most  marked.  The  patient  is  boisterous,  incoherent,  and 
noisy,  and  he  sometimes  gives  vent  to  passing  delusions. 
Destructiveness  and  impulsiveness  are  frequent,  and  indeed  all 
the  usual  signs  and  symptoms  already  mentioned  are  present. 


MANIA 


119 


Fig.  23.— Chronic  mania. 


120  MENTAL   DISEASES 

Chronic  Mania. — This  is  a  condition  that  supervenes  on 
those  acute  cases  which,  after  the  lapse  of  a  year,  do  not  recover. 
The  patient  often  has  a  Fixed  Delusion  and  the  ordinary  signs 
of  Mania  in  a  reduced  degree.  If  several  delusions  are  present, 
they  are  not  systematised,  as  in  Paranoia .  In  time  the  memory 
becomes  affected  and  the  process  tends  to  Secondary  Dementia, 
to  which  it  may  be  regarded  as  a  halfway  house.  In  some 
cases  the  excitement  is  increased  in  a  rhythmic  manner  until 
the  patient  becomes  more  and  more  weak-minded,  although 
occasionally  improvement  occurs.  The  majority  of  cases, 
however,  are  only  fit  for  institution  care. 

Recurrent  Mania. — This  may  be  Simple,  or  Acute, 
resembling  the  Periodic  type,  but  the  attacks  occur  at  more 
irregular  intervals,  and  the  patient  generally  becomes 
demented. 

Course. — An  attack  of  Acute  Mania  frequently  lasts 
about  six  months ;  after  twelve  months  it  may  be  regarded 
as  becoming  chronic.  Recovery  occurs  in  most  cases  and  it 
may  occasionally  be  delayed  until  the  second  year.  A  few 
cases  die  of  exhaustion  or  of  some  intercurrent  affection, 
whilst  the  remainder  become  chronic  and  frequently  end  in 
Dementia.  Some  so-called  recoveries  are  only  partial  cures, 
and  a  condition  of  depression  or  weak-mindedness  with  lack 
of  self-reliance  results,  or  else  a  fixed  delusion  remains. 

Diagnosis. — This  should  be  made  from  Acute  Delirium, 
which  is  a  grave  disorder,  with  a  rise  of  temperature,  and  it  is 
almost  invariably  fatal.  The  Delirium  from  Alcohol  and  other 
conditions  must  also  be  excluded.  The  excitement  in  Con- 
fusional  insanity  occurs  with  hallucinations  and  memory 
defects,  and  the  patient  becomes  disorientated.  General 
Paralysis  must  be  distinguished  by  a  careful  examination  for 
the  motor  signs  of  that  disease.  The  excitement  of  Epilepsy 
and  Hysteria  must  also  be  differentiated.  Paranoia  and 
Dementia  Prsecox  may  be  excluded  by  the  gradual  onset, 
together  with  persecutory  delusions  as  well  as  exaltation  in 
the  former,  and  weak-mindedness  and  mannerisms  accom- 
panying the  latter. 

Prognosis. — This  is  decidedly  good  for  first  attacks,  and 
quite  60  %  recover.  Repeated  relapses  point  to  the  liability 
of  chronicity,  and  the  majority  terminate  in  Dementia.     Per- 


MANIA  121 

sistent  dirty  habits  render  the  outlook  serious,  as  does  also  the 
complication  of  auditory  hallucinations.  As  to  the  predic- 
tion of  future  recurrence,  there  are  at  present  no  available 
data,  but  a  strong  family  history  of  insanity  predisposes  to 
a  recurrence.  It  may,  however,  be  guarded  against  by 
judicious  management,  which  may  be  necessary  for  many  years 
in  some  cases. 

Patholog-y. — Little  of  a  positive  nature  can  be  asserted, 
but  the  theory  of  defective  metabolism  of  the  cortex  of  the 
brain  offers  the  best  explanation.  Toxins  are  probably  pro- 
duced in  situ  which  cannot  be  eliminated  readily,  although 
it  would  seem  they  do  disappear  in  some  cases  as  suddenly 
as  they  appear.  Histologically  but  little  abnormal  is  seen 
in  the  nerve  cells  in  recent  cases.  The  circulation  is  prob- 
ably only  affected  secondarily.  Craig  has  pointed  out  that 
there  is  a  tendency  to  low  blood-pressure  in  many  cases. 
What  toxic  relationship  Mania  bears  to  Melancholia  is  at 
present  purely  conjectural. 

Treatment. — Every  case  of  Acute  Mania  is  most  satis- 
factorily treated  in  an  institution,  unless  the  means  are  ample 
for  special  single  care.  Even  then,  it  is  usually  best  to  remove 
the  patient  from  home  surroundings,  and  certification  will 
have  to  be  resorted  to.  The  noise  and  destructiveness  which 
commonly  accompany  Mania,  satisfy  the  relations  that  some 
change  must  be  made,  and  the  physician  has  a  freer  hand  than 
he  has  in  cases  of  Melancholia.  The  lay  mind  is  willing  to 
accept  the  fact  that  a  patient  is  insane  when  he  strips  himself 
of  clothing  and  is  smashing  up  the  furniture  or  threatening 
violence.  It  is,  however,  frequently  difficult  to  act  in  the 
premonitory  stage,  when  the  patient  still  has  some  self-control, 
but  is  restless  and  sleepless  and  is  to  some  extent  amenable 
to  reason.  If  there  is  a  history  of  a  previous  attack,  it  is 
always  best  to  advise  removal  forthwith,  as  the  best  chance  of 
recovery.  Rest,  rather  than  exercise,  should  be  the  rule  for 
the  proper  treatment  of  the  patient.  Trained  mental  nurses 
must  be  engaged,  who  will  carry  out  the  exact  orders  of  the 
medical  man  in  charge.  Some  patients  can,  with  tact,  be 
managed  in  bed,  and  external  stimuli  should  be  removed  as  far 
as  possible  and  the  room  be  darkened.  A  tepid  bath,  lasting 
from  half  to  one  hour  each  morning  or  even  longer  in  some 


122  MENTAL   DISEASES 

cases,  is  efficacious  in  reducing  excitement,  and  the  patient 
will  then  not  infrequently  return  to  bed  quietly.     When  bed 
treatment  cannot  be  satisfactorily  carried  out,  rest  can  still  be 
to  some  extent  enforced  by  the  use  of  lounge  chairs  in  a 
garden  ;  even  walking  exercise  should  be  discouraged  as  much 
as   possible.     The   idea   of   allowing   a   Maniacal   patient   to 
exhaust  his  energies  by  violent  exercise  should  be  seriously 
deprecated.     After  the  acute  symptoms  have  subsided,  and 
the  patient  shows  improvement,  a  certain  amount  of  latitude 
as  regards  exercise  may  be  safely  permitted.     The  excitement 
may  be  so  dangerous  at  times  that  the  patient  is  best  off  in 
a  specialty  padded  room.     This  often  obviates  any  attempts 
at  struggling  with  nurses,  and  enables  the  patient  to  obtain 
rest.     Suicidal  notions  are  uncommon,  but  a  patient  suffering 
from   Acute    Mania    will   impulsively  or   accidentally  injure 
himself  unless  properly  looked  after.     Therefore,  it  is  best,  in  a 
private  house,  to  have  a  room  on  the  ground  floor,  and  to  have 
most,  if  not  all  of  the  furniture  moved  therefrom.     Especially 
must  all  dangerous  weapons   be  removed,   so  that  risks   be 
minimised  as  far  as  possible.     Next  to  rest,  the  most  important 
point  is  to  see  that  the  patient  is  properly  nourished.     Some 
patients  overload  their  stomachs  at    one  meal,   and  refuse 
everything  at  another.    Li  the  acute  state,  fluid  diet  is  generally 
best.     Two  pints  of  egg-and-milk  in  the  form  of  custard  three 
or  four  times  a  day  suits  most  cases   admirabty.     The  food 
may  be  varied  occasionally  with  a  little  soup  thickened  with 
vermicelli.     Stimulants  should  be  for  the  most  part  prohibited 
unless  the  pulse  flags.     Absolute  refusal  of  food,  which  occurs 
sometimes,  must  be  treated  by  the  use  of  the  nasal  or  oesopha- 
geal tube,  as  is  mentioned  in  the  Chapter  on  General  Treat- 
ment.    A  chart  should  be  kept  showing  the  amount  of  sleep. 
If  a  patient  sleeps  less  than  six  hours  in  forty-eight  in  spite 
of  nourishment,   some  sedative  or  hypnotic   should   be   ad- 
ministered.     For  this  purpose    Sulphonal    in  gr.  xx  to  xxx 
doses  is  largely  given.    It  must  be  remembered  that  its  action 
is   somewhat   delayed   and  is   also   cumulative.     During  its 
administration    the    bowels    should    be     kept    freely    open. 
Trional  in  gr.  xx   doses   has   a   more  immediate   effect,   but 
does  not  last  so  long.     In  an  emergencj^,  Hyoscine  Hydro- 
bromate  gr.  yig-  togr.  ^V,  administered  subcutaneously,  has  a 


ALTERNATING  INSANITY  123 

wonderfully  calming  influence,  which  may  in  some  cases  be 
continued  by  giving  3ss  to  3j  doses  of  Potassium  Bromide 
every  four  hours.  The  state  of  the  bowels  requires  careful 
regulation,  as  excitement  is  generally  increased  with  any 
tendency  to  constipation.  The  evacuation  of  the  bladder  at 
regular  intervals  should  receive  attention. 

As  the  patient  convalesces,  tonics  may  be  indicated,  and 
he  may  be  allowed  to  take  part  in  occupations  and  amuse- 
ments. Cases  of  post-maniacal  Stupor  require  energetic 
treatment  by  prompt  and  stimulating  nourishment. 


ALTERNATING    INSANITY 

This  is  the  Periodic  or  Circular  form  of  Maniacal-Depressive 
insanity,  which  is  much  less  common  than  Mania  or  Melancholia 
of  the  Intermittent  type.  It  is  more  intractable,  and  some- 
times lasts  in  its  different  phases  throughout  the  life  of  the 
patient  when  once  fully  established,  although  it  does  not  as 
a  rule  tend  so  much  to  Dementia.  It  is  mostly  seen  in  the 
cultured  classes,  and  where  the  tendency  to  mental  insta- 
bility is  marked.  It  is  frequently  also  called  Folie  Circulaire. 
The  intervals  between  the  attacks  are  of  short  duration, 
and  the  course  of  the  attacks  can  almost  with  certainty  be 
predicted.  The  most  typical  form  is  an  attack  of  Mania, 
which  is  immediately  followed  by  one  of  Melancholia,  and 
then  by  a  normal  period  in  a  regular  cycle  (Fig.  24).  In  some 
cases  the  order  is  Melancholia,  Mania,  Normal  State  ;  or  the 
Normal  State  may  intervene  between  each  phase  of  Melan- 
cholia and  Mania ;  or  the  Melancholia  and  Mania  may  run 
consecutively  without  any  normal  period  at  all.  In  other 
cases  there  is  a  regular  sequence  of  either  Mania  and  the 
Normal  State,  or  of  Melancholia  and  the  Normal  State,  and 
finally  there  are  a  few  cases  which  present  an  irregular  type 
of  sequence.  But  whatever  intervals  and  sequence  occur, 
the  attacks  are  sure  to  be  repeated — and  o\\\j  rarely  does  the 
patient  recover  absolutely — or  to  result  in  a  chronic  state  of 
Mania  or  Melancholia. 

The  exaltation  in  the  Maniacal  phase  comes  and  goes 
gradually^  as  a  rule,  and  the  symptoms  and  signs  of  ordinary 


124 


MENTAL   DISEASES 


CIRCULAR 


TRUE  ALTER>4ATING 


Intermittent  Mania  are  exhibited  in  varying  degree,  but  on 
the  whole  they  resemble  the  simple  type  of  the  disorder.  The 
Melancholic  stage  also  resembles  an  attack  of  Melancholia, 
with  its  depression  and  general  attitude,  and  sometimes  the 

patient  is  Stuporous  during 
part  of  the  process.  Nothing 
definite  is  laiown  as  to  the 
etiology  and  pathology  of  the 
condition. 

Treatment.— Although  a 
certain  amount  of  rhythm  or 
periodicity  is  common  in  the 
mental  constitution  of  many 
individuals  who  may  be  re- 
garded as  normal,  it  reaches 
its  climax  in  this  disorder.  A 
patient  will  pass  through  days 
or  weeks  of  excitement,  in 
which  the  appropriate  treat- 
ment for  Mania  is  necessary, 
and  an  attack  of  depression 
will  follow,  in  which  the  thera- 
peutic measures  advocated  in 
Melancholia  are  called  for. 
There  seems  nothing  to  break 
the  sequence,  and  each  phase 
is  a  faithful  replica  of  the 
corresponding  phase  that  has  preceded  it.  In  rare  cases  the 
cycles  are  very  short,  viz.  there  are  alternate  days  of  excite- 
ment and  depression,  or  apathy.  Many  patients  are  able  to 
live  out  of  asylum  control  in  the  charge  of  suitable  nurses ; 
but  for  some  it  is  advisable,  when  the  attack  of  excitement 
is  a  long  one,  to  seek  institution  care,  and  leave  of  absence 
can  be  obtained  during  the  quiescent  or  lucid  intervals  for  their 
return  home. 


PERIODIC 


r^, 


Fig.  24. 
Diagram  of  alternating  insanity. 


CHAPTER   X 
ACUTE    CONFUSIONAL  INSANITY 

CoNFUSiONAL  INSANITY  is  a  disorder  in  whicli,  unlike  the 
Maniacal-Depressive  group  where  emotional  disturbance  is 
the  predominant  factor,  the  confusional  element  is  most 
marked,  and  it  is  accompanied  bj^  various  sensory  aberrations. 
There  is  also,  as  a  rule,  more  evidence  of  some  definite  toxic 
or  exhausting  process  in  the  etiology,  and  the  physical  signs 
are  more  pronounced.  The  hereditarj^  stock  is  generally 
unsound,  although  it  may  only  be  slightly  tainted  with  insanity. 
Acute  Confusional  insanity  is  the  commonest  chnical  type ; 
Delirium  results  when  the  mental  disturbance  is  temporary  and 
is  accompanied  by  muttering  and  marked  sensory  aberration 
- — ^in  a  distinctive  form  it  is  described  as  Acute  Delirium  ;  Stupor 
is  the  condition  when  confusion  is  such  as  to  leave  the  mind 
almost  a  blank. 

When  certain  individuals  become  abnormalh^  fatigued  b}" 
muscular  or  intellectual  pursuits  carried  to  excess,  their  nervous 
systems  are  such  that  they  are  peculiarly  susceptible  to  alcohol 
and  other  toxic  influences,  as  well  as  to  the  effects  of  ordinary 
stresses.  In  such  cases,  unless  a  state  of  chronic  Neurasthenia 
supervenes,  Acute  Confusional  or  Exhaustion  insanity  is  most 
likely  to  be  produced.  It  occurs  usually  in  early  adult  life, 
and  affects  both  sexes  equally.  Leaving  out  cases  associated 
with  Alcohol,  the  Confusional  or  Intoxication  psychoses  are 
certainly  less  common  than  the  Maniacal-Depressive  group. 

Etiology. — There  is  nearly  always  a  history  of  neurotic 
inheritance,  and  sometimes  of  mental  instability.  The  patient's 
nervous  energy,  which  is  apt  to  be  run  down  too  easily,  has 
usually  received  some  further  check  to  recuperation,  by  an 
increase'  of  mental  or  phj^sical  exertion,  accompanied  often 
by  anxiety  and  worry.     The  condition  sometimes  arises  after 

125 


126  MENTAL   DISEASES 

Operations,  and  then  possibly  the  Anaesthetic  plays  a  role  in 
the  causation.  The  debiUtating  effects  of  Influenza  frequently 
give  rise  to  this  form  of  insanity,  but  it  also  occurs  after 
Typhoid  and  other  fevers.  Profound  Anaemia  is  liable  to 
cause  this  affection  in  certain  individuals,  and  when  insanity 
occurs  after  Childbirth  it  usually  conforms  to  this  type.  It 
is  a  special  feature  of  the  insanity  of  Alcohol,  and  of  drug 
states,  including  Lead,  also  of  Cerebral  Arteriopathic  disease. 
Syphilitic  or  otherwise. 

Physical  Signs. — The  patient  is  thin  and  badly  nourished, 
he  looks  debilitated,  and  the  blood  is  impoverished.  The  skin 
has  an  earthy  hue,  is  clammy,  and  it  often  has  a  peculiar  odour. 
The  pulse  is  small,  frequent,  and  of  low  tension ;  the  heart 
sounds  are  weak.  The  temperature  is  subnormal.  The 
digestion  is  deranged  and  constipation  is  the  rule.  The  urine 
is  high  coloured.  In  women,  the  menses  are  irregular.  The 
muscular  system  exhibits  loss  of  tone,  and  tremors  are  not 
infrequent.  The  laiee-jerks  are  increased.  The  pupils  are 
dilated. 

Mental  Symptoms. — The  patient  shows  great  restlessness 
and  is  unable  to  obtain  propet  sleep  at  night.  Sometimes  the 
insomnia  is  absolute,  and  it  requires  immediate  attention.  The 
special  senses  at  first  are  in  a  state  of  hyperactivity.  Anaes- 
thesia has  been  noted  at  the  extremities  of  both  arms  and 
legs.  In  advanced  cases  the  patient's  perceptive  powers  are 
paralysed,  so  that  he  does  not  recognize  objects  (imperception) 
and  mistakes  the  identity  of  his  relations.  Short  of  this, 
confusion  of  ideas  is  marked,  and  there  is  retardation  in  the 
flow  of  ideas.  Memory  for  existing  events  is  quite  disordered. 
The  patient  is  in  a  bewildered  state,  owing  to  functional  dis- 
sociation, and  either  does  not  appreciate  the  nature  of  questions 
or  gives  wrong  answers.  Fleeting  delusions  occur.  At  times 
the  patient  may  be  elated,  at  other  times  depressed,  but  the 
emotional  sphere,  for  the  most  part,  is  in  a  negative  state.  The 
patient  is  unable  to  judge  of  his  surroundings,  and  shows  no 
proper  appreciation  of  time  or  place  (disorientation).  Hal- 
lucinations are  always  present  and  are  characteristic  of  the 
disorder,  so  that  some  authors  have  called  it  "  Hallucinatory 
insanity."  Patients  see  "  visions  "  or  hear  "  voices,"  and 
the  other  senses  are  also  commonly  involved.     He  sees  specks 


ACUTE  CONFUSIONAL  INSANITY  127 


Fig.  25. — Acute  Confusional  insanity. 


128  MENTAL  DISEASES 

in  his  food,  which  he  says  smells  and  tastes  evil,  so  that  fre- 
quently he  refuses  to  eat  voluntarily,  and  has  to  be  forciblj" 
fed.  In  a  severe  case  the  patient  is  wet  and  dirtjdn  his  habits, 
and  gives  wa}"  to  masturbation.  He  moves  about  aimlessl}^, 
he  is  often  resistive,  and  he  becomes  excited  and  incoherent. 
The  patient  remains  in  an  acute  state  for  some  months,  and 
then  gradually  improves,  sleeping  better  at  night,  and  taking 
more  notice  of  his  surroundings.  To  him  his  illness  has  seemed 
like  a  terrifjdng  dream,  the  details  of  which  are  blurred  in  his 
memory.  Occasionallj^  there  is  a  relapse,  and  sometimes  several 
attacks  occur  during  the  lifetime  of  an  individual,  but  this  is 
rare. 

Varieties. — According  as  to  whether  the  disorder  is  accom- 
panied by  depression  or  exaltation,  authors  have  made  a 
distinction  into  :  (1)  a  Depressed  form  and  (2)  an  Exalted 
form.  There  is  also  (3)  a  Katatonic  form,  in  which  the  patient 
is  Stuporous  or  Mute  and  the  condition  closely  resembles  a  case 
of  Dementia  Prsecox. 

Diagnosis. — ^It  is  distinguished  from  ordinar}'  Mania' or 
Melancholia  (Maniacal-Depressive  msanit}^),  by  the  absence 
of  pronounced  emotional  disorder,  and  the  presence  of  marked 
confusion  wdth  hallucinations  and  other  sensorj'  disturbances. 
Dementia  Preecox  generally  develops  in  an  insidious  manner, 
and  until  the  pronounced  symptoms  of  mannerisms,  negativism, 
etc.,  appear,  it  may  be  impossible  to  differentiate  it  from  the 
Katatonic  variety  of  Confusional  insanity. 

Prognosis. — About  80%  of  cases  recover  in  six  to  twelve 
months.  The  remainder  become  chronic  or  demented,  except 
a  few  that  die  from  profound  exhaustion  or  from  some  com- 
plication. As  has  been  mentioned,  some  patients  relapse  when 
improvement  seems  to  be  established,  and  therefore  supervision 
and  care  are  needed  until  recovery  is  certain.  The  future  of 
such  cases  should  be  regulated,  to  guard  against  the  possibilit}' 
of  recurrence. 

Pathology. — The  post-mortem  changes  reveal  a  congested 
state  of  the  pia -arachnoid.  Histologicall}^  the  cortical  nerve 
cells  ioaa,y  show  e\adence  of  chromatoh'sis,  but  nothing  patho- 
gnomonic has  so  far  been  discovered.  The  blood  is  in  a  chlorotic 
state,  and  it  is  suggested  that  the  condition  is  brought  about 
by  morbid  metabolic  processes  interfering  with  the  nutrition 


ACUTE   CONFUSIONAL   INSANITY  129 

of  the  nerve  cells,  whereby  katabolism  is  m  ex-cess  of  repair. 
In  cases  associated  with  Alcoholism,  an  acute  attack  is  often 
superimposed  on  a  chronic  condition  betokening  a  degree  of 
Dementia,  with  the  usual  cortical  characteristics  which  are 
mentioned  later. 

Treatment. — As  the  disorder  is  largely  due  to  exhaustion  or 
pathological  fatigue,  and  is,  in  some  cases,  produced  by  Alcohol 
and  other  toxins,  the  treatment  must  be  directed  accordingly. 
Absolute  rest  in  bed  should  be  enjoined,  with  the  assistance  of 
skilled  nurses.  Unless  the  means  are  ample,  the  patient  will 
have  the  best  chance  of  recovery  in  an  institution.  The  bowels 
require  regulation  by  laxatives  and  saline  draughts.  The  diet 
during  the  acute  stage  must  be  of  a  fluid  nature,  and  on  no 
account  should  refusal  of  food  be  allowed  to  continue,  the  tube 
being  resorted  to  if  necessary.  Egg  and  milk,  one  or  two  pints, 
three  or  four  times  a  day,  with  the  addition  of  cream,  forms 
the  best  nourishment.  If  indigestion  or  sickness  ensues,  a 
little  peptonising  agent  should  be  added.  It  is  usual  also  to 
give  a  basin  of  beef -tea  or  soup  once  or  twice  a  day  with  a  little 
bread  or  toast  softened  therein,  if  the  patient  will  take  solid 
food.  Stimulants  are  best  wdthheld,  unless  the  patient  becomes 
coUapsed,  in  which  case,  brandy  ,or  champagne  should  be 
administered,  and  it  may  be  necessary  to  give  intravenous 
saline  injections  in  some  cases.  If  the  insomnia  does  not  yield 
to  natural  means,  a  hypnotic  may  be  necessary  in  the  form 
of  Paraldehyde  3j  to  3i]  i^  the  food — or  in  a  little  syrup, 
peppermint  water,  or  quillaia ;  or  i^mylene  Hydrate  3j  to  3ij 
can  be  given,  which  suits  Exhaustion  cases  better  than  the 
Sulphonal  group  or  the  Opiates.  As  the  patient  improves.  Iron 
may  be  given  to  restore  the  impoverished  condition  of  the 
blood,  and  the  patient  should  gradually  be  placed  on  solid  diet. 
Exercise  must  only  be  allowed  in  the  strictest  moderation. 
The  visits  of  relatives  should  from  the  begirming  be  restricted 
as  much  as  possible,  and  all  excitement  be  avoided  for  weeks 
after  recovery,  to  ward  off  all  chance  of  relapse. 


ACUTE    DELIRIUM 

Ordinary  Delirium  is,  for  the  most  part,  due  to  toxins  and 
is  frequently  met  with  as  a  complication  of  many  physical 


130  MENTAL  DISEASES 

disorders,  such  as  Pneumonia,  Septicaemia,  Enteric  Fever,  etc., 
especially  when  associated  with  a  continuous  high  temperature. 
It  is  not  unusual  in  cases  even  of  slight  pyrexia  in  young  people 
with  a  neurotic  temperament.  It  occurs  in  starvation  and 
profound  nervous  prostration,  and  in  certain  special  toxic  or 
drug  states — such  as  those  produced  by  Belladonna  and  Can- 
nabis Lidica.  These  are  described,  together  with  Delirium 
Tremens,  in  the  Chapter  on  Alcohol  and  Insanity.  Delirium 
also  results  from  extreme  confusion,  which  is  sometimes  met 
with  in  Epilepsy,  General  Paralysis,  and  Dementia  Prsecox. 

Acute  Delirium,  or  Acute  Delirious  Mania  as  the  disorder  is 
also  known,  is  regarded  by  some  authorities  as  an  exaggerated 
degree  of  Acute  Mania  (Maniacal-Depressive  insanity),  and  by 
others,  as  an  extreme  form  of  Acute  Confusional  insanity,  but 
it  is  best  described  as  a  distinct  affection.  It  is  accompanied 
by  symptoms  of  extreme  exhaustion,  and  it  frequently  ends 
fatally  in  a  few  weeks,  and  sometimes  even  in  a  few  days. 
To  this  may  appropriately  be  applied  the  term  "  Brain 
Fever  "  which  is  used  by  the  laity  to  include  a  number 
of  different  mental  disorders.  In  Germany  it  is  known  also 
as  Collapse  Delirium.  It  was  formerly  called  Bell's  Disease, 
and  is  happily  a  somewhat  rare  affection,  and  when  it  occurs 
it  does  so  in  the  upper  rather  than  in  the  lower  classes  of  society. 

Etiology. — Overwork,  physical  and  mental  stress  are  the 
common  antecedents  in  the  history  of  this  disorder.  There  is 
usually  some  hereditary  taint  in  the  family.  No  definite  toxin 
has  been  discovered,  but  various  organisms  have  been  described 
in  the  blood  and  cerebro-spinal  fluid,  and  also  in  the  brain  tissue 
of  patients  who  have  died  from  this  disease. 

Physical  Signs .  — The  patient  becomes  anaemic,  has  a  sallow 
complexion,  and  soon  develops  a  cachectic  appearance.  The 
pulse  is  rapid — 120  to  150,  and  the  heart-beat  is  lacking  in 
force.  There  is  always  a  rise  in  temperature  which  makes 
this  disorder  distinctive— about  100°  F.  to  102°  F.  The 
appetite  is  lost,  all  food  is  commonly  refused,  and  he  usually 
has  to  be  tube-fed.  The  tongue  is  dry,  and  coated  with  a  dirty 
brown  fur,  and  sordes  are  present  on  the  lips.  The  bowels 
may  be  constipated,  and  when  they  act,  the  patient  frequently 
pays  no  heed.     The  urine  is  also  likely  to  dribble  away. 

Mental  Symptoms. — After  a  prodromal  period  of  a  few 


ACUTE   DELIRIIBI  131 

days,  ill  which  the  patient  shows  inabihty  to  attend  to  his 
work,  and  is  restless  and  depressed,  ^^-ith  sleepless  nights,  he 
loses  his  self-control  and  becomes  excited  and  resistive.  His 
special  senses  and  perception  are  at  first  hyperacute,  then  they 
•  become  further  disordered,  and  are  finally  dulled.  Thought 
and  memory  are  deranged,  and  delusions  occur  with  or  without 
hallucinations.  As  the  morbid  process  increases,  the  patient 
becomes  completely  incoherent,  and  he  scarcelj^  recognizes  his 
friends.  He  becomes  quite  disorientated  both  as  to  time  and 
place.  He  shouts  and  uses  unintelligible  language.  The 
raving  and  restlessness  continue  by  day  and  by  night,  mthout 
any  intermission,  until  the  patient  is  completely  exhausted. 
He  is  always  on  the  move  and  never  seems  to  sleep. 

Diagnosis. — This  is  usuall}'  sufficiently  clear,  omng  to  the 
acuteness  of  the  symptoms,  together  \nth  the  rise  of  tempera- 
ture, and  the  early  advent  of  prostration  which  distinguishes 
it  from  other  mental  disorders.  The  bodily  organs  should  be 
examined  to  exclude  the  possibility  of  Delirium  from  pneumonia 
and  other  diseases. 

Prognosis. — At  least  90%  of  cases  end  fatally,  djdng  from 
exhaustion  and  heart  failure  in  the  course  of  two  to  three  weeks. 
Most  of  the  cases  that  survive  become  weak-minded,  and  have 
to  live  under  supervision. 

Pathology. — The  post-mortem  examinations  reveal  extreme 
congestion  of  the  brain  and  meninges,  and  often  minute  hsemor- 
hages  are  to  be  found,  but  it  is  surprising  that  more  changes 
are  not  to  be  discovered.  Cocci  and  bacilli  have  been  described 
by  Italian  observers,  but  confirmation  is  needed. 

Treatment. — The  patient  must  be  put  to  bed  and  induced 
to  take  as  much  stimulating  nourishment  as  possible.  Eggs, 
milk,  and  beef  essences  should  be  given ;  and,  as  the  patient 
usually  refuses  food,  the  tube  must  be  used.  To  help  to  produce 
sleep  the  room  should  be  darkened,  and  absolute  quietude 
enjoined.  Alcoholic  stimulants  are  indicated  in  most  cases. 
Paraldehyde  in  3]  to  3iij  doses  should  be  given,  or  some  other 
non-depressant  hj^pnotic.  The  state  of  the  bowels  must  be 
regulated,  and  the  patient  carefully  nursed.  Sometimes  a 
spurious  improvement  occurs,  followed  by  a  relapse.  Chloro- 
form has  been  given  to  anaesthetise  the  patient  to  sleep,  with 
satisfactory  results  in  a  few  cases. 


132  MENTAL   DISEASES 


STUPOR 


The  condition,  here  described,  is  that  of  a  temporary  sus- 
pension of  the  mental  fmictions,  which  is  closely  allied  to,  and 
often  arises  from.  Acute  Confusional  or  Exhaustion  insanity. 
It  is  pre-eminently  due  to  a  drain  on  the  highest  centres  of  the 
nervous  system,  and  when  the  proper  energy  of  these  centres 
is  restored  under  treatment,  return  of  the  normal  mental  func- 
tions results.  Such  depletion  of  nervous  energy  of  the  brain  may 
be  primarily  due  to  some  profound  mental  shock  or  delusion, 
or  it  rasby  be  secondarily  caused  by  prolonged  excitement  and 
general  debility  from  sexual  excess  or  masturbation.  Kraepelin 
regards  Stupor  chiefly  as  a  phase  of  Maniacal-Depressive 
insanity,  because  it  does  sometimes  alternate  ^^ith.,  or  follow 
upon,  Mania  and  Melancholia,  but  it  must  be  remembered  that 
the  condition  is  also  seen  in  General  Paralysis,  Epilepsy,  and 
other  insanities.  The  older  authors  used  the  term  Acute 
Dementia  for  these  cases,  but  by  common  consent  it  has  become 
customary  to  reserve  the  term  Dementia  for  states  exhibiting 
an  absence  of  mental  functions  due  to  organic  destruction  of 
nerve  cells,  and  without  hope  of  recovery.  Stupor  is  not 
common,  and  as  in  Somnambuhsm  or  Trance,  to  which  it  is 
closely  allied,  there  are  all  degrees  of  loss  of  consciousness. 

Etiology. — In  the  majority  of  cases,  masturbation  or  sexual 
excess  is  the  chief  factor  in  causation.  It  therefore  occurs,  for 
the  most  part,  in  adolescent  patients.  It  does,  however,  also 
arise  from  extreme  mental  or  physical  exhaustion  due  to  other 
stresses,  and  especially  from  sudden  fright  or  shock,  or  from 
a  deep-seated  delusion. 

Physical  Signs. — As  a  rule  the  patients  are  in  poor  health, 
they  are  anaemic  and  badly  nourished.  This  is  more  marked 
in  the  secondary  cases  than  in  those  due  to  sudden  emotional 
stress.  The  temperature  is  inclined  to  be  subnormal.  The  hair 
becomes  dry  and  brittle.  The  hands  and  feet  are  cold,  and  are 
frequently  red  from  congestion,  or  even  blue  and  oedematous. 
The  blood  tension  is  reduced,  and  the  pulse  is  variable.  Respira- 
tion is  slow  and  shallow.  The  urine  is  deficient  and  high- 
coloured.  In  females  the  menses  are  absent.  The  tongue 
becomes  furred,  saHva  often  dribbles  from  the  mouth ;  constipa- 
tion is  frequent,  probably  from  lack  of  sufficient  ahmentary 


STUPOR  133 

secretion,  as  well  as  from  deficient  peristalsis.  The  pupils  are 
unduly  dilated.  The  superficial  reflexes  are  diminished,  and  the 
knee-jerks  are  increased.  Stoddart  has  pointed  out  that  peri- 
pheral anaesthesia  is  present .  In  marked  cases  of  Anergic  Stupor 
the  patient's  limbs  are  motionless,  and  fall  in  any  position  they 
are  placed  in  by  gravity ;  in  other  cases  they  adopt  the  attitudes 
artificially  induced  by  the  medical  attendant  {Catalepsy  or 
flexibilitas  cerea) ;  or  the  patients  with  Delusional  Stupor 
become  resistive  and  rigid,  and  often  refuse  nourishment,  thus 
resembling  Katatonia  (Dementia  Prsecox). 

Mental  Symptoms. — These  are  for  the  most  part  negative. 
The  patient's  face  loses  its  normal  expression  and  he  gazes 
vacantly  into  space.  He  is  generally  absolutely  mute,  and 
takes  no  heed  of  his  surroundings.  Unless  he  is  in  bed,  he 
stands  or  sits  in  the  same  pose  all  day.  He  takes  no  food, 
even  if  it  is  placed  in  front  of  him,  and  would  starve  if  he 
were  not  fed.  Most  patients  will  eat  and  drink  when  spoon- 
fed. Cases  that  are  resistive  require  the  tube.  The  majority 
of  them  take  no  notice  of  the  calls  of  nature,  whilst  others 
retire  for  the  purpose  at  the  proper  time.  Particularly  in  the 
Anergic  variety  are  thought  and  perception  in  abeyance,  and 
there  is  a  complete  absence  of  emotion.  The  memory  of  these 
patients  is  usually  gone  whilst  the  Stupor  lasts,  and  on 
recovery  no  details  of  the  illness  can  be  recollected.  In  the 
resistive  cases,  however,  patients  have  some  perception  and 
memory,  but  their  actions  are,  for  the  time,  paralysed  by  some 
dominating  delusion.  Very  occasionally,  during  an  attack  of 
Stupor,  impulses  may  overcome  the  inaction,  resulting  in 
violence  or  self-destruction.  Nevertheless,  -most  cases  of 
Stupor  cannot  be  regarded  as  actively  suicidal.  How  much 
Stuporous  patients  really  sleep,  it  is  difficult  to  say,  as  they 
remain  motionless  in  bed,  and  often  with  ej^es  closed. 

Varieties. — Stupor  may  best  be  divided  into  (1)  Primary 
and  (2)  Secondary. 

Primary  Stupor,  which  is  usually  Imown  as  Aiiergic  Stupor, 
may  develop  gradually,  or  more  generally  suddenly.  In  like 
manner  may  the  attack  end,  in  the  course  of  a  few  months, 
though  it  may  be  prolonged  even  to  two  or  three  years. 
Recurrence  is  sometimes  a  feature,  or  it  may  occasionally  adopt 
a  Periodic  form  alternating  with  either  Mania  or  Melancholia. 


134  MENTAL   DISEASES 

Secondary  Stupor  is  that  variety  which  follows  on  an 
Acute  Melancholic  state,  accompanied  by  some  profound 
delusion — Delusional  or  Resistive  Stupor,  or  it  ma}^  be  the 
result  of  Acute  Mania,  on  the  road  to  recovery.  It  may  also 
be  that  induced  by  the  excitement  of  General  Paralysis,  or  of 
Epilepsy.  In  Dementia  Prsecox  it  is  called  Katatonic  Stupor 
{vide  p.  158). 

Diagnosis. — Anergic  Stupor  can  be  diagnosed  by  the 
extreme  lack  of  tone  in  the  muscles  {hypotonia),  as  well  as 
by  the  negation  of  mental  sjTnptoms.  The  chief  condition 
likely  to  be  confounded  with  Stupor,  is  Dementia  supervening 
on  an  acute  attack  of  insanity.  The  historj'  will  therefore 
be  a  guide.  It  must,  however,  be  mentioned  that  a  small 
number  of  cases  of  Stupor  do  not  recover,  and  drift  into  a 
state  of  Dementia  after  a  few  years.  Reaction  to  Thyroid 
Extract  sometimes  differentiates  Stupor  from  Dementia. 
Some  cases  of  profound  Idiocy  resemble  those  of  Stupor.  The 
history  will  again  clear  up  the  diagnosis.  The  coma  of  cerebral 
tumours  and  of  other  conditions  has  also  been  mistaken  for 
Stupor.  It  is,  therefore,  always  necessary  to  examine  carefully 
for  the  phj'sical  signs  of  organic  cerebral  mischief,  bearing  in 
mind  the  possibility^  of  General  Paralysis. 

Prognosis. — In  Anergic  Stupor  this  is  most  favourable. 
The  majority  recover,  sometimes  passing  through  an  acute 
attack  of  excitement  or  depression  before  they  are  well.  The 
outlook  for  the  Resistive  Delusional  cases  is  not  so  good ;  some 
end  fatally  from  lung  complications,  others  become  chronic, 
whilst  some  partially  recover  after  a  long  period  of  years. 

Pathology. — This  is  at  present  purely  speculative,  and  the 
condition  probabh"  is  due  to  an  extreme  form  of  morbid  c^iLO- 
metabolism  producing  auto-intoxication.  No  definite  changes 
have  been  discovered  post  mortem  or  by  histological  methods. 

Treatment. — This  consists  in  careful  nursing,  and  in  a 
superabundance  of  nourishing  diet.  The  Anergic  cases  usuall}' 
allow  themselves  to  be  fed  mth  a  spoon  or  a  feeding  cup. 
Milk,  four  to  six  pints  a  da}^  A\dth  eggs,  should  be  the  staple 
diet,  together  with  a  basin  of  soup  in  the  middle  of  the  day. 
Stimulants  as  a  rule  do  no  good.  Resistive  cases  maj^  require 
feeding  -with,  the  tube,  and  should  on  no  account  be  allowed  to 
abstain  from  food  for  any  length  of  time. 


STUPOR  135 

Hypnotics  are  not  indicated.  An  occasional  tonic  of  Iron 
and  Nux  Vomica  is  helpful,  especially  when  the  patient  shows 
signs  of  returning  mental  power.  A  system  of  rest  is  better 
than  making  the  patient  take  exercise,  although  it  is  advisable 
for  him  to  spend  part  of  the  day  in  the  open  air.  It  is  of  no 
use  coercing  the  patient,  in  the  hope  of  trjdng  to  rouse  his 
mental  activities.  Tepid  baths,  and  a  certain  amount  of 
massage,  morning  and  evening,  can  be  employed  mth  advantage 
to  assist  assimilation  or  to  improve  the  circulation.  Constipa- 
tion and  retention  of  urine  require  attention.  If  the  patient 
remains  in  the  same  state  for  a  period  of  six  months,  it  is  well 
to  try  a  week's  course  of  Thj^roid  Extract.  Not  that  recovery 
is  to  be  claimed  as  directly  due  to  this  treatment,  but  it  is 
judicious  to  cause  a  little  artificial  excitement  at  regulated 
periods  in  the  hope  of  warding  off  Dementia.  The  method  of 
administration  is  described  in  the  Chapter  on  General  Treatment 
{vide  p.  310).  Patients  should  be  regularly  weighed  once  a 
week  and  should  not  be  left  alone,  on  account  of  the  possibility 
of  impulses  to  suicide  or  violence. 


CHAPTER   XI 

PARANOIA   (SYSTEMATISED  DELUSIONAL  INSANITY) 

This  is  a  chronic  incurable  disorder,  which  must  be  regarded 
as  a  constitutional  mental  distortion  rather  than  a  disease.  It- 
cannot  be  said  to  be  congenital,  although  some  cases  have 
shown  traces  of  mental  peculiarity  from  childhood.  It  would 
seem  as  if  the  lines  of  evolution  proceeded  in  a  normal  mannei 
until  maturit}^  and  that  between  the  ages  of  30  and  40  a 
certain  degeneration  in  the  association  neurons  occurred, 
whereby  the  patient  was  rendered  abnormally  sensitive  to 
certain  impressions,  coupled  with  a  morbid  development  of 
the  egoistic  faculties.  The  patient  reacts  abnormally  to  his 
environment  owing  to  a  chronic  perversion  of  his  feehngs,  the 
result  of  which  is  that  he  lives  continuously  in  a  deluded  state. 
The  older  writers  used  the  term  Monomania  for  this  disorder, 
as  the  patient  can  frequently  discourse  rationally  on  ordinary 
topics  outside  his  circumscribed  sphere  of  insanity,  but  it  has 
become  usual  to  use  the  term  Paranoia  {naqd,  beyond ;  voeco 
reason)  for  this  affection  by  modern  authors.  The  main 
feature  of  the  disorder  is  that  the  patient  possesses  delusions 
which  are  systematised ;  that  is  to  say,  every  little  detail  in 
the  environment  is  closely  entwined  within  the  fabric  of  the 
patient's  morbid  imagination.  He  thus  has  an  erroneous  ex- 
planation of  ever3i}liing  that  concerns  himself,  but  his  remarks 
on  other  matters  may  show  no  want  of  normal  judgment. 
The  condition,  when  once  established,  is  of  a  chronic  nature,  and 
although  the  patient's  mental  life  becomes  entirely  narrowed, 
there  is  usually  little  or  no  failure  of  memory,  and  but  slight 
tendency  to  Dementia.  Percy  Smith  and  others  have  raised 
the  point  as  to  whether  the  disorder  is  primarily  intellectual 
or  emotional ;  some  authorities  maintain  that  the  ideational 
life  is  first  affected,  as  it  is  indeed  more  ob^dous  in  the  later 

1.36 


PARANOIA  137 

stages ;  but  the  majority  of  cases  appear  to  develop  delusions 
on  a  groundwork  of  exaggerated  egoism,  due  to  a  chronic 
exaltation  of  the  feelings  resulting  in  a  changed  personality. 

Etiology. — In  about  50%  of  cases  there  is  a  family  histor}^ 
of  insanity.  Rarely  is  it  possible  to  ssij  when  the  disorder 
really  commences,  for,  as  a  rule,  it  is  a  gradual  evolution  of 
an  abnormal  character.  The  patient  has  usually  been  regarded 
as  suspicious,  inclined  to  solitude,  and  as  being  inordinately 
conceited  and  sometimes  shy  or  jealous.  It  is  slightly  more  com- 
mon in  the  male  sex,  and  the  majority  of  cases  are  unmarried. 
It  reaches  its  full  development  usually  between  40  and  50. 

Physical  Signs. — Stigmata  of  degeneracj^  are  to  be  noticed 
in  some  cases,  such  as  an  abnormally  shaped  head,  irregular 
ears,  or  an  arched  palate.  When  first  placed  under  care,  the 
patient  looks  ill,  because  he  has  probably  passed  through  an 
anxious  period  of  insomnia  owing  to  his  delusions.  He  has  also 
usually  lost  weight  owdng  to  insufficiency  of  food. 

Mental  Symptoms. — An  element  of  suspicion  and  persecu- 
tion colours  the  whole  mental  life  of  the  patient .  There  is  a  want 
of  healthy  reaction  to  the  environment.  He  does  not  consider 
he  is  treated  with  the  courtesy  that  is  due  to  him,  and  sees 
some  hidden  underhand  meaning  in  the  ordinary  incidents  of 
life.  His  sense  of  self-importance  appears  to  have  outgrown 
the  dimensions  his  fellow  creatures  have  meted  out  to  him ; 
he  therefore  harbours  grievances  and  shuns  the  society  of 
others.  Many  individuals  pass  their  whole  lives  in  this  con- 
dition, and  yet  are  able  to  follow  their  occupations — Resigned 
Paranoiacs.  They  are  looked  upon  as  cranks  that  are  best 
not  interfered  mth.  Others  of  a  more  retahatory  disposition 
and  with  a  basis  of  strong  individualit}',  become  possessed  of 
delusions  which  dominate  their  actions.  Tor  a  while  they  are 
able  to  hold  themselves  in  check,  until  some  action  brings  them 
into  trouble.  The  Paranoiac  is  apt  to  fix  his  annoyances  on 
some  particular  person,  and  he  may  write  letters  molesting 
him ;  or  he  accuses  him  of  insulting  him,  or  of  being  the  author 
of  his  imaginary  persecution,  and  he  demands  redress.  As  a 
result  of  solitude  and  morbid  introspection,  the  association 
currents  become  further  disturbed.  The  sensory  centres  and 
organs  are  hypersensitive,  and  are  prone  to  become  active  from 
within   by   a   sj^stem   of    quasi   back-working ;     the   ordinary 


138  MENTAL   DISEASES 

impressions  from  the  external  world  thus  become  misinter- 
preted, and  illusions  only  frequently  are  the  consequence. 
Sooner  or  later  hallucinations  of  the  senses  are  apt  to  develop. 
The  patient  misconstrues  the  words  and  actions  of  casual 
passers-by,  and  when  communing  alone  he  hears  the  telephonic 
"  voice  "  of  his  accuser.  All  the  special  senses  may  be  involved. 
At  first,  perhaps  only  suspicious  about  his  food,  he  rapidly 
becomes  convinced  he  is  being  poisoned,  and  straightway 
begins  to  starve  himself.  He  not  infrequently  imagines  he 
smells  foul  odours  in  his  room,  which  he  says  are  pumped  up 
through  his  chimney,  or  that  vermin  crawl  about  him  all 
night,  or  that  his  sexual  organs  are  tampered  with  in  his 
sleep.  Many  explain  their  sensations  as  due  to  mesmerism, 
electricity,  magnetism,  or  X-rays  which  are  played  upon  them 
by  their  persecutors.  Sometimes  a  patient  suspects  an 
organised  body  of  men  of  forming  a  conspiracy  against  him, 
such  as  the  Government,  the  Freemasons,  or  a  Religious  Sect. 
He  finds  references  to  himself  in  newspapers  and  books — ideas 
of  reference,  or  symbolism,  and  annoying  innuendoes  appear  to 
him  everywhere.  Many  patients  complain  that  their  thoughts 
are  read  and  are  translated  into  language.  The  ordinary 
events  of  their  past  lives  are  worked  up  to  fit  into  the  system 
of  their  delusions.  Sometimes  the  delusions  are  of  an  amorous 
or  jealous  nature,  and  patients  persecute  ladies  with  their 
attentions.  A  certain  proportion  of  Paranoiacs  are  sexual  in- 
verts and  they  sometimes  dress  up  in  the  garb  of  the  opposite 
sex.  Some  have  delusions  regarding  their  health  ;  they  imagine 
their  strength  has  been  sapped  by  some  person  and  accordingly 
they  are  always  consulting  doctors  and  quacks.  Whatever  the 
nature  of  the  persecution  may  be,  it  is  nearly  always  associated 
with,  and  sometimes  almost  replaced  by,  delusions  of  grandeur. 
A  frequent  statement  by  a  Paranoiac  is  that  he  is  of  royal 
descent  or  that  he  is  a  prophet.  At  first  vague  in  character, 
the  delusions  become  well-defined  and  organised  into  a  regular 
system,  giving  an  insane  theory  of  the  incidents  of  his  life. 
When  the  case  has  gone  thus  far,  it  is  high  time  that  the  patient 
should  be  certified  and  placed  under  care,  both  in  his  own 
interest  and  especially  in  that  of  the  general  public.  Very 
frequently  he  has  secreted  some  weapon,  such  as  a  revolver, 
to  be  used  when  occasion  arises,  and  he  must  therefore  be 


PARANOIA  139 

regarded  as  a  dangerous  member  of  society.  When  at  first 
placed  under  restraint,  he  is  a  difficult  case  to  manage,  and 
invariably  he  becomes  worse  until  he  can  adapt  himself  to  the 
new  routine  of  life.  Paranoiacs  are  prolific  letter-writers,  and 
they  never  seem  to  tire  in  sending  off  their  communications 
to  various  authorities  retailing  their  grievances.  In  tone, 
some  of  these  betoken  incoherence,  but  this  is  generally  limited 
to  the  circumscribed  area  of  their  delusions,  and,  as  has  already 
been  mentioned,  it  is  rarely  that  Dementia  or  memory  defects 
supervene. 

Varieties. — Clouston,  following  the  older  authorities,  uses 
the  term  Monomania  for  these  cases,  and  subdivides  them  into  : 
{a)  Monomania  of  grandeur  and  pride ;  (6)  Monomania  of  sus- 
picion ;  and  (c)  Monomania  of  unseen  agency  (mesmerism, 
mysticism,  telepathy,  electricity,  etc.)  :  all  of  them,  in  variable 
degrees,  becoming  the  victims  of  ideas  of  persecution.  This 
subdivision  does  not  cover  all  the  cases,  and  the  following 
classification  of  Paranoia,  based  on  that  elaborated  by  Stoddart, 
will  be  found  useful  by  the  student  : — 

A. — Ego-centrics  (Paranoia  proper)  or  cases  in  which  the 
personality  of  the  patient  is  most  affected  and  the  delusions 
are  systematised. 

(1)  Exalted   Paranoia — where    delusions    of    exaltation    are 

uppermost. 

(2)  Persecutory   Paranoia — in    which   persecution    and   sus- 

picion are  most  marked. 

(3)  Querulant  Paranoia — the    patient's  essential    nature  is 

retaliatory,  and  his  delusions  render  him  litigious  and 
hostile. 

(4)  Religious  Paranoia — this    is    usually  accompanied    by 

obvious  aural  hallucinations,  and  the  patient  believes 
himself  in  direct  communication  with  God. 

(5)  Amorous  Paranoia — the  patient    pursues    his    advances 

to  some  person  of  the  opposite  sex,  being  under  the 
delusion  that  such  person  is  in  love  with  him  or  her. 
Closely  allied  are  adolescent  cases  that  disown  their 
parents  owing  to  delusions. 

(6)  Hypochondriacal   Paranoia — which  is   closely   allied   to 

Hypochondriacal    Melancholia,    but    differs    from    it 


140  MENTAL   DISEASES 

inasmuch  as  there  is  always  an  element  of  persecution 
present.  The  patient  imagines  he  is  impotent  and  that 
his  sexual  or  other  organs  have  been  ruined  or  that  his 
general  health  has  been  sapped,  and  that  he  is  dying. 

B. — Eccentrics,  sometimes  called  Mattoids.  These  form  a 
large  class  differing  in  variable  degree  from  the  normal.  They 
include  cranks,  faddists  and  narrow-minded  individuals,  who 
are  on  the  border-line  of  insanity ;  they  rarely  need  to  be  placed 
under  care,  although  thej^  are  somewhat  of  a  nuisance  to  the 
community.  Some  authorities  indeed  consider  that  from  this 
class  are  begotten  the  Christian  Scientists,  Vegetarians,  Anti- 
vivisectionists,  and  other  an ti -persons.  Many  of  them  can 
hardly  be  regarded  as  of  high  mental  calibre,  although  their 
disregard  of  conventional  ideas  is  not  in  itself  evidence  of  any 
disorder  of  mind. 

Diagnosis .  — The  insidious  and  gradual  onset  of  the  disorder, 
together  with  the  tendency  to  organisation  of  the  delusions 
into  a  regular  system,  is  characteristic  of  Paranoia.  A  fixed 
delusion  as  a  sequela  of  an  attack  of  Intermittent  insanity  can 
be  distinguished  by  the  history,  and  also  by  the  absence  of  a 
definite  vein  of  persecution.  Dementia  Paranoides,  i.  e.  the 
Paranoidal  form  of  Dementia  Prsecox,  resembles  Paranoia ; 
but  is  to  be  marked  off  by  the  development  of  mannerisms, 
weak-mindedness,  loss  of  memory  and  greater  liability  to 
hallucinations.  Alcoholic  pseudo -Paranoia  is  sometimes  ac- 
companied by  delusions  of  persecution ;  the  history  and 
general  bodily  condition  will  indicate  the  differentiation. 
General  Paralysis  must  be  excluded  by  a  careful  examination 
of  physical  signs. 

Prognosis. — As  the  disorder  is  the  result  of  a  morbid  evolu- 
tion, no  hope  of  permanent  recovery  can  be  entertained.  It 
is  true  that  now  and  then  remissions  occur  in  the  early  stages, 
and  patients  are  discharged  from  institutions ;  but  they 
invariably  have  to  return  in  the  course  of  a  few  months,  and 
finally  have  to  spend  their  lives  under  supervision.  Some  cases 
are  suicidal  and  have  to  be  watched. 

It  speaks  well  for  asylum  administration  that  Paranoiacs 
frequently  live  comparatively  happy  lives,  notwithstanding 
certain  restrictions  that  are  inevitable  for  their  welfare  and 
the  safet}^  of  others. 


PARANOIA  141 

Pathology. — Alteration  in  convolutional  pattern  hay  been 
noted  in  some  cases,  but  otherwise  nothing  definite  is  known, 
and  the  brain  frequentl}^  presents  a  normal  appearance.  The 
special  senses  of  Paranoiacs  during  life  are  always  hyperactive 
or  perverted,  but  no  trace  of  disorder  can  be  found  'post  mortem. 
An  ingrained  morbid  sensitiveness  seems  to  be  at  the  root  of 
the  malad}^,  leading  to  the  development  of  systematised 
delusions  as  the  patient  passes  through  life. 

Treatment. — The  medical  attendant  is  frequently  onh^  con- 
sulted when  some  overt  act  has  been  committed,  bringing  the 
mental  state  of  the  patient  into  question.  During  the  develop- 
ment of  the  disorder,  many  patients  are  able  to  conceal  their 
delusions  from  their  relations.  Sedatives  and  other  medicinal 
measures  do  but  little  good,  unless  the  patient  is  removed  from 
home  surroundings.  Although  it  is  unusual  to  advocate  travel 
in  early  cases  of  insanity,  it  does  sometimes  seem  to  serve  to 
stave  off,  if  not  to  arrest,  the  development  of  Paranoia  in  some 
instances.  These  cases,  must,  however,  be  selected  \vith  due 
caution,  and  the  patient  be  sent  in  the  care  of  a  medical 
attendant,  companion,  or  nurse.  When  the  disease  is  fully  estab- 
lished and  the  delusions  are  systematised,  so  that  the  patient 
cannot  follow  his  occupation,  the  proper  course  is  to  certify 
the  patient  and  to  send  him  to  an  institution.  The  student 
should  bear  in  mind  that  nearly  ever^^  pronounced  Paranoiac  is 
a  potential  homicide,  and  that  he  is  sometimes  suicidal  also. 

Communicated  Insanity. — It  cannot  be  said  that  insanity 
is  in  any  sense  contagious,  otherwise  those  who  have  charge  of 
the  insane  would  break  down  oftener  than  they  do.  It  is  true 
that  care  is  taken  to  obtain  a  staff  of  mentally  well-balanced 
individuals,  but  occasionally  a  weak-minded  nurse  manages 
to  join  the  staff,  and  becomes  unhinged  by  the  development  of 
some  delusion.  It  has  occasionally  happened  that  a  nurse, 
having  charge  of  a  persecutory  Paranoiac,  has  become  the 
victim  of  delusions  for  a  while.  Two  members  of  a  family  may 
become  insane  at  almost  the  same  time  without  the  one  having 
any  effect  on  the  other.  The  term  communicated  insanity,  which 
is  also  known  as  jolie  a  deux,  or  induced  insanity,  usually  appHes 
to  cases  of  Paranoia,  where  the  delusions  of  the  active  agent 
have  been  passed  on  to  another  person  by  imitation  or  sugges- 
tion. The  second  person  is  nearly  always  a  blood  relation,  has 
similar  mental  constitution,  and  is  usually  of  the  female  sex. 


CHAPTER   XII 
IDIOCY,    AND    IMBECILITY 

Amentia,  Mental  Deficiency,  or  Arrested  Mental  Develop- 
ment, differs  from  other  varieties  of  insanity  in  being  a  failure 
of  evolution  rather  than  a  dissolution  of  existing  mental 
functions.  It  exists  in  all  degrees  from  mere  simple  mental 
dullness  and  backwardness  to  congenital  feeble-mindedness, 
moral  degeneracy,  imbecility,  and  idiocy. 

Idiots  are  defined  as  persons  so  deeply  defective  in  mind 
from  birth,  or  from  an  early  age,  as  to  be  unable  to  guard 
themselves  against  common  physical  dangers. 

Imbeciles  are  persons  in  whose  case  there  exists  from 
birth,  or  from  an  early  age,  mental  defectiveness  not  amount- 
ing to  idiocy,  yet  so  pronounced  that  they  are  incapable  of 
managing  themselves  or  their  affairs,  or,  in  the  case  of  children, 
of  being  taught  to  do  so. 

Etiology. — In  the  more  pronounced  cases  of  idiocy  and 
imbecility,  a  neuropathic  heredity  is  almost  certain  to  be 
elicited.  The  defect  in  vitality  shows  itself  specially  in  a  want 
of  cerebral  development  from  failure  of  nerve  force.  The 
association  of  epilepsy  with  idiocy  is  a  particularly  close  one. 
Alcoholism  in  the  parents  is  accredited  with  being  a  common 
cause.  This  is  so  far  true  that  an  alcoholic  parentage  means 
in  most  cases  an  unstable  nervous  inheritance,  and  that  the 
abuse  of  alcohol,  or  a  diseased  condition  of  any  kind  in  the 
parents,  at  the  time  of  conception,  cannot  be  supposed  to 
conduce  to  healthy  offspring.  This  applies  also  to  the  mother 
during  pregnancy,  especially  in  the  earlier  months ;  emotional 
shocks  or  injury  may  produce  failure  in  nutrition  of  the  foetus, 
leading  later  to  an  arrest  of  mental  growth.  This  may  account 
for  its  abnormal  frequency  in  illegitimate  children.  A  bad 
confinement  is  often  held  to  be  the  cause ;    prolonged  labour, 

142 


IDIOCY  AND   IMBECILITY 


143 


the  use  of  forceps  and  of  anaesthetics,  are  all  blamed  in  some 
cases,  but  it  must  be  borne  in  mind  that  an  irregularly  formed 
head  is  often  the  cause  of  difficult  childbirth.  It  is,  moreover, 
a  fact  that  idiocy  is  commoner  in  boys  than  in  girls,  and  that 
the  male  infant's  head  is  proportionately  larger  than  that  of 
the  female.     It  also  occurs  more  frequently  in  first  pregnancies 


Fig.  26. — Genetous  idiocy. 

and  last  pregnancies,  the  former  bemg  probably  due  to  the 
exigencies  of  a  first  labour,  and  the  latter  to  the  failure  of  the 
mother's  nervous  energy.  Organic  brain-trouble  in  the  child, 
inherited  Syphilis,  or  acquired  disease  such  as  Cerebral  Menin- 
gitis or  Haemorrhage  with  resulting  paralysis,  lead  to  mental 
arrest,  and  so  do  Scarlet  fever  and  other  exanthems.  Convul- 
sions from  teething  indicate  an  innate  nerve  instability  which 
sometimes  produces  mental  defect.      Consanguinity    has   an 


144  MENTAL   DISEASES 

increasing  effect,  if  neuroses  occur  in  both  parents.  The  chil- 
dren of  aged  parents,  or  of  those  disproportionate  in  age,  are 
frequently  defective,  and  sometimes  also  children  of  premature 
birth.  Early  ossification  of  the  skull  signifies  that  there  is 
already  brain  defect,  rather  than  that  the  brain  is  prevented 
from  growing. 


Varieties  of  Idiocy 

1.  Genetous. — This  class  consists  of  those  idiots  that  are 
more  essentially  congenital  than  the  other  varieties,  and  in 
which  no  obvious  cause  can  be  traced  during  life,  although 
there  is  sometimes  a  history  of  a  fall,  or  of  a  difficult  labour. 
They  are  stunted  in  growth,  but  they  present  no  deformities, 
and  some  are  improvable  to  a  certain  extent,  but  the  more 
marked  degrees  of  so-called  Infantilism  have  but  feeble  vital- 
ity.   Closely  allied  is  the  Amaurotic  Family  Idiocy  of  Jews. 

2 .  Mongolian. — These  have  the  facial  expression  of  China- 
men, with  flattened  noses  and  obliquely  set  eyes.  The  tongue 
is  enlarged  and  fissured,  the  hands  and  feet  are  stumpy,  the 
skin  is  dry,  and  they  have  a  dwarfish  figure.  Their  disposition 
is  affectionate  as  a  rule.  They  often  have  heart  trouble  and 
they  are  especially  liable  to  diarrhoea. 

3.  Microcephalic. — These  idiots  look  as  if  they  were 
brothers  and  sisters,  and  are  of  a  bird-like  appearance.  The 
circumference  of  the  head  is  less  than  seventeen  inches.  They 
are  very  active  and  imitative,  and  are  fond  of  music.  They  are 
often  quarrelsome  and  difficult  to  manage,  but  many  of  them 
can  be  trained  to  a  certain  extent  so  as  to  be  kept  out  of 
mischief. 

4.  Hydrocephalic. — This  is  due  to  closure  of  the  foramen 
of  Magendie  at  birth  or  later,  thus  causing  interference  with  the 
drainage  of  the  cerebro-spinal  fluid  through  the  spinal  canal. 
The  head  is  considerably  enlarged,  especially  in  the  temporal 
region,  so  that  there  is  increased  width  between  the  eyes,  and 
the  eyeballs  are  sunken.  Many  are  unable  to  walk.  They  are 
usually  quiet,  and  they  seldom  live  long.  The  bony  structure  of 
the  skull  is  generally  thin  and  occasionally  almost  diaphanous. 

5.  Hypertrophic. — This  is  a  rare  condition  in  which  there 
is  inflammatory  hypertrophy  of  the  cerebral  interstitial  tissues. 


IDIOCY  AND  IMBECILITY 


145 


Fig.  27. — Group  of  microcephalic  idiots  in  one  family. 


146 


MENTAL  DISEASES 


The  head  is  elongated  and  larger  than  usual,  especially  above 
the  superciliary  ridges. 

6.  Eclampsic. — This  term  is  more  particularly  applied  to 
those  cases  that  exhibit  convulsions  during  teething.  They 
are  passionate  and  difficult  to  train. 

7.  Epileptic. — If  epilepsy  be  developed  in  children  before 


Fig.  28. — Epileptic  idiocy. 

the  age  of  seven  years,  mental  enfeeblement  amounting  to 
idiocy  is  sure  to  accompany  it.  Such  children  may  be  specially 
schooled,  but  whatever  is  learnt  is  usually  forgotten  again, 
at  every  recurrence  of  fits.  They  form  a  numerous  class,  and 
are  frequently  irritable  and  impulsive,  and  the  prognosis  is  bad, 
although  some  improve  under  the  influence  of  Bromides. 

8.  Paralytic.     This    is    usually   the   result    of    Cerebral 
Haemorrhage  from  trauma  at  birth,  or  from  a  fall  during  early 


IDIOCY   AND   IMBECILITY  ]47 

life,  producing  hemiplegia  or  diplegia,  sometimes  with  spasticity 
or  choreiform  movements.  These  cases  are  very  manageable, 
and  are  capable  of  being  taught. 

9.  Inflammatory. — This  is  a  condition  of  chronic  Ence- 
phalitis set  up  by  Scarlet  Fever,  or  by  some  other  exanthem. 
Some  cases  are  amenable  to  training,  but  the  majority  are 
unfavourable. 

10.  Syphilitic. — The  usual  signs  of  congenital  specific 
disease  are  present.  The  condition  is  somewhat  rare,  and 
seldom  develops  until  the  eruption  of  the  permanent  teeth 
begins,  when  convulsions  may  occur  and  mental  arrest  ensues. 

11.  Idiocy  from  Deprivation  of  the  Senses. — This 
arises  if  two  of  the  higher  senses  are  deficient,  such  as  Sight 
and  Hearing.  These  cases  are  difficult  to  teach,  but  many 
of  the  blind,  and  deaf  mutes,  can  be  thereby  considerably 
improved  so  as  to  maintain  themselves  to  some  extent, 
and  indeed  can  be  educated  to  a  certain  degree  of  mental 
development. 

12.  Cretinism. — This  has  been  aptly  described  as  an  in- 
fantile form  of  Myxoedema,  and  it  occurs  sporadically  in  this 
country.  The  thyroid  gland  is  either  absent,  or  a  small  goitre 
is  present.  The  child's  body  and  limbs  are  slow  in  growth. 
The  skin  is  harsh,  the  lips  and  tongue  are  thick,  and  the 
abdomen  is  prominent.  Mental  development  is  slow,  but  these 
cases  exhibit  no  objectionable  characteristics. 

Physical  Signs. — The  body  in  idiocy  is  generally  ill- 
developed  or  malformed,  and  frequently  presents  stigmata  of 
degeneracy.  The  muscles  are  flabby  and  co-ordination  is  faulty, 
tremors  and  irregular  movements  are  sometimes  present.  The 
limbs  are  stunted  and  some  cases  are  unable  to  walk.  The  skin 
is  coarse,  the  hair  is  deficient  and  brittle.  The  head  may  be 
abnormally  small  or  large,  the  forehead  and  lower  jaw  receding, 
and  the  back  of  the  cranium  flattened.  The  facial  expression 
is  weak.  The  palate  is  often  arched.  Dentition  is  defective 
and  grinding  of  the  teeth  may  occur.  The  ears  show  various 
abnormalities.  The  eyes  may  be  placed  too  close  together,  or 
too  far  apart,  or  may  be  situated  obliquely.  The  throat  may 
indicate  the  presence  of  enlarged  tonsils  and  adenoids.  The 
chest  is  often  pigeon-breasted,  resulting  in  shallow  respiration. 
The  circulation  is  usually  feeble  and  the  heart  is  at  times 


148  MENTAL   DISEASES 

congenitally  diseased,  with  a  patent  foramen  ovale.  Idiots  are 
very  prone  to  diarrhoea,  gastric  disturbances,  etc.,  and  many 
pay  no  attention  to  the  calls  of  nature.  The  females  that 
attain  maturity  rarely  menstruate,  but  some  are  precocious  in 
this  respect;   one   or,  both   testes  in   the   male   may  be   un- 


li(^.  29. — Cretinism. 

descended.  Masturbation  in  both  sexes  is  common,  it  may 
occur  even  as  early  as  six  months  of  age,  and  in  such  a  case 
it  is  most  intractable. 

Mental  Symptoms. — In  idiocy  these  vary  according  to 
the  amount  of  failure  of  development.  An  infant  that  does 
not  attempt  to  suck  at  the  teat,  after  repeated  trials,  must 
be  regarded  as  deficient.     This  is  usuallj^  accompanied  by  an 


IDIOCY   AND   IMBECILITY  149 

absence  of  the  ordinary  micro-kinetic  movements,  the  child  is 
badly  nourished,  and  scarcely  utters  a  sound.  If  the  child 
lives,  and  is  fed  and  nurtured,  it  fails  to  put  on  proper  weight, 
and  is  abnormally  slow  in  its  future  development  as  regards 
crawling  and  walking ;  and  the  muscular  co-ordination  in  the 
hands  is  feeble.  In  the  worst  forms,  speech  is  not  attained 
at  all  or  is  defective.  It  has  been  computed  that  about  6%  of 
idiots  and  imbeciles  are  blind,  this  being  mostly  due  to  optic 
atrophy.  The  other  special  senses  are  also  occasionally 
blunted  and  some  cases  are  deaf  mutes.  All  deaf  mutes, 
however,  are  by  no  means  feeble-minded ;  indeed  many  are 
taught  by  the  system  of  lip-reading  both  to  understand  and 
even  to  talk,  and  thus  almost  lose  their  mutism.  Idiots 
in  many  instances  hear,  but  do  not  attend ;  some  are,  how- 
ever, attracted  by  the  rhythm  of  music.  They  do  not  generally 
appreciate  differences  in  smell,  whilst  they  are  sometimes  so 
degraded  as  to  eat  filth.  Sensation  to  pain  causes  a  normal 
reaction  in  most  cases,  whilst  ordinary  tactile  sensation  is 
difficult  to  gauge.  The  faculty  of  attention,  both  voluntary 
and  instinctive,  is  very  weak  in  idiots.  The  memory  also  is 
generally  affected.  This  accounts  to  some  extent  for  their  lack 
of  perception,  and  therefore  for  an  extreme  poverty  of  ideas. 
The  ideas  they  possess  are  always  of  the  simplest  nature,  and 
the  associations  formed  are  of  the  feeblest  character.  They 
have  no  powers  of  abstraction,  and  therefore  are  unable  to 
arrive  at  any  proper  judgment.  They  are  practically  devoid 
of  the  higher  emotions,  and  many  are  passionate  and  cruel. 
For  them,  as  a  whole,  there  is  no  sense  of  right  or  wrong. 
Truth,  morality,  religion  have  for  them  no  meaning.  They 
have  passing  likes  and  dislikes,  but  their  laughter  and  noises 
are  mostly  devoid  of  significance.  They  have  no  notion  of 
the  future,  and  live  selfishly  in  the  present.  The  lowest  types 
lead  purely  vegetative  lives,  and  have  to  be  tended  for  their 
personal  wants,  and  be  protected  from  harm.  Sleep  is  in  general 
increased  but  disturbed,  although  some  are  very  restless. 
Some  idiots  are  capable  of  being  trained  up  to  a  certain  point ; 
being  very  imitative,  they  can  be  taught  simple  handicrafts, 
but  their  work  requires  constant  supervision.  Speech  is  some- 
times accomplished,  in  variable  degrees  of  imperfection,  but  read- 
ing and  writing,  however  rudimentary,  are  seldom  acquired. 


150  MENTAL   DISEASES 

Imbecility  occurs  in  all  grades,  and  is  sometimes  associated 
with  poor  physical  health.  Many  cases  appear  sharp  and  even 
clever,  but  more  often  this  is  in  a  particular  direction,  such  as 
memory  for  dates,  or  certain  arithmetical  calculations,  while 
the  association  of  their  ideas  is  always  limited.  Voluntary 
attention  is  feeble.  Their  will-power  is  ill-developed,  and  at 
most  they  can  only  be  regarded  as  being  partially  responsible 
for  their  actions.  Their  emotions  and  instincts  are  strong, 
but  on  a  low  level  and  are  sometimes  perverted.  They  are 
passionate,  and  their  impulses  frequently  bring  them  into 
trouble.  Their  speech  is  often  a  stammer,  and  is  deficient  in 
its  vocabulary,  but  they  can  read  and  write  up  to  a  certain 
educational  standard.  They  are  able  to  dress,  and  care  for 
themselves,  and  to  take  part  in  simple  pastimes,  and  many  are 
musical.  But  their  powers  of  concentration  are  too  weak  for 
them  to  be  capable  of  any  solid  work,  yet  many  are  able  to 
carry  out  simple  manual  operations  satisfactorily,  although 
their  labours  are  generally  unremunerative.  Imbeciles,  there- 
fore, are  unable  to  maintain  themselves,  or,  at  any  rate,  cannot 
earn  their  livelihood  in  the  social  status  in  which  they  are 
born. 

Diagnosis. — The  several  signs  and  symptoms  usually 
establish  the  diagnosis  with  regard  to  idiocy.  Sometimes, 
however,  development  does  not  proceed  evenly,  and  a  dull  or 
backward  child  may  not  talk  until  the  age  of  four,  and  yet  turn 
out  quite  normal.  In  an  imbecile  of  mature  age  the  history  is 
important,  otherwise  a  case  of  imbecility  may  be  mistaken  for 
a  dement. 

Prognosis. — Suitable  education  and  training  tend  to 
improve  the  majority  of  idiots.  The  worst  cases  are  those  that 
show  no  desire  for  food  and  drink,  that  are  wet  and  dirty,  that 
cannot  walk,  and  that  are  Epileptic.  Being  in  a  low  state  of 
nutrition  they  are  liable  to  intercurrent  maladies,  especially 
Phthisis.  Many  die  young  and  few  attain  mid-life.  Imbeciles 
are,  of  course,  capable  of  further  training,  but  none  can  ever 
be  brought  to  a  normal  state.     They  may  live  on  to  old  age. 

Pathology. — The  skull  may  be  deformed,  the  bones  thick- 
ened, or  diaphanous  in  places.  The  membranes  are  usually 
opaque.  The  brain  varies  in  size  and  weight,  and  as  a  rule 
there  is  excess  of  cerebro-spinal  fluid  in  the  sub-arachnoid  space 


IDIOCY  AND   IMBECILITY  151 

and  ventricles.  The  latter  may  be  enormously  distended  in 
Hydrocephalus.  The  brain  is  wanting  in  its  convolutions,  the 
cortex  is  thin  and  there  is  considerable  overgrowth  of  neuroglial 
tissue,  producing  sclerosis  in  some  cases,  whilst  in  Hypertrophic 
idiocy  the  process  is  probably  inflammatory  in  origin.  Occa- 
sionally there  is  a  cavity  in  the  white  matter  (porencephaly), 
the  result  of  a  cyst  from  old  haemorrhage,  which  sometimes 
opens  into  one  of  the  lateral  ventricles.  The  cerebellum,  as 
well  as  the  cerebrum,  may  be  atrophied  on  one  or  both  sides, 
but  generally  the  former  is  conspicuous  from  deficient  over- 
lapping of  the  latter.  Cysts  and  tuberculous  growths  are  to  be 
met  with,  sometimes.  Microscopically,  the  nerve  cells  are 
immature,  being  deficient  in  number  and  quality,  the  defect 
showing  itself  also  in  the  paucity  of  the  nerve  processes. 
'  Treatment. — An  idiot,  whether  he  be  rich  or  poor,  is  best 
cared  for  in  a  special  establishment.  He  is  far  happier  in 
association  with  others  of  his  own  class  than  he  is  if  he  remains 
at  home.  Kindness  and  patience  are  necessary  in  his  training. 
It  is  best  to  withhold  pleasures  when  correction  is  necessary, 
and  punishment  must  not  be  inflicted  in  appealing  to  a 
defective  moral  nature.  The  idiot  requires  to  be  warmly 
clad,  and  to  live  in  the  most  hygienic  conditions.  The  diet 
should  be  nutritious,  but  it  should  comprise  little  meat,  and 
the  meals  must  be  closely  supervised.  His  training  has  to 
be  carried  out  by  nurses  and  special  instructors.  Habits  of 
cleanliness  can  be  established  in  most  cases  by  patient  per- 
severance, yet  some  are  hopeless  in  this  respect.  He  should 
also  be  taught  to  wash  and  dress  himself  as  far  as  is  possible. 
Various  methods  are  used  to  attract  and  stimulate  the 
attention  of  an  idiot.  If  educable  at  all,  his  special  senses 
have  in  turn  to  be  cultivated  by  the  use  of  bright  balls, 
skeins  of  wool,  bells,  etc.  Co-ordination  of  muscular  move- 
ments must  be  taught  by  using  wooden  bricks  or  ninepins, 
and  by  physical  exercises  and  drills.  Some  idiots,  however, 
are  never  able  to  walk,  in  spite  of  special  devices  such  as  swings, 
etc.  Objects  of  danger,  such  as  fire,  and  sharp  or  pointed 
instruments,  must  be  gradually  introduced  to  the  child's  mind, 
yet  some  never  learn  to  appreciate  their  dangerous  nature. 
As  with  the  normal  child,  the  idiot,  to  a  certain  extent,  under- 
stands what  is  said  to  him,  before  he  is  able  to  make  use  of 


152  MENTAL  DISEASES 

articulate  speech,  however  defective.  Pains  must  be  taken 
by  the  instructor  to  encourage  the  idiot  to  imitate  the  move- 
ment of  his  tongue  and  Ups,  to  produce  sounds  which  he  learns 
to  associate  with  simple  objects.  Carved  objects  of  animals, 
etc.,  are  excellent  illustrations.  The  idiot  rarely  acquires 
speech  after  seven,  if  patient  tuition  has  been  carried  out 
before.  An  idiot  may  scribble  with  a  pencil,  but  only  the 
highest  grade  can  ever  write  intelligible  words.  Some  idiots 
can  frequently  be  properly  trained  to  simple  manual  occupa- 
tions, such  as  basket- making.  Idiots  are  liable  to  colds  and 
minor  ailments,  which  require  treatment  on  ordinary  lines. 
Sedatives  are  occasionally  required  to  subdue  excitement, 
and  of  these,  the  Bromides  can  be  recommended.  As  a  rule 
idiots  sleep  well,  sometimes  by  day  as  well  as  by  night,  and 
they  should  require  no  hypnotics.  Cretins  should  have 
Thyroid  Extract  administered  to  them  in  regulated  doses. 

The  milder  cases  of  idiocy  should  be  occupied  as  much  as 
possible  with  outdoor  pursuits,  and  they  should  live  on  plain 
simple  diet.  Idiots  and  Imbeciles  may  be  certified  and  placed 
in  homes  and  institutions  under  the  Mental  Deficiency  Act  or 
in  those  under  the  Lunacy  Act. 


CONGENITAL     FEEBLE-MINDEDNESS 

Feeble-minded  persons  are  those  in  whom  there  exists 
from  birth  or  from  an  early  age  mental  defectiveness  not 
amounting  to  imbecility,  yet  so  pronounced  that  they  require 
care,  supervision,  and  control  for.  their  own  protection,  or  for 
the  protection  of  others,  or,  in  the  case  of  children,  that  they 
by  reason  of  such  defectiveness  appear  to  be  permanently 
incapable  of  receiving  proper  benefit  from  the  instruction  in 
ordinary  schools. 

These  individuals,  who  in  reality  are  high-grade  imbeciles, 
have  hitherto  been  allowed  to  pass  as  normal  beings  and  to 
remain  at  large.  They  fail  in  the  competition  of  life  with 
ordinary  people  owing  to  their  mental  weakness.  Amongst 
them  are  wastrels,  ne'er-do-wells,  idlers,  prostitutes  and 
inebriates.     It  has  been  estimated  that  20 ^^^  of  the  pauper 


CONGENITAL   FEEBLE-MINDEDNESS  153 

population,  20%  of  criminals,  10%  of  vagrants,  60%  of  the 
inmates  of  inebriate  reformatories,  and  50%  of  girls  admitted 
into  Magdalen  homes  are  feeble-minded.  Some  of  these 
persons  cannot  apply  their  attention  to  work  and  either  will  not 
or  cannot  find  employment,  and  therefore  they  prey  on  others 
and  border  on  the  criminal  classes.  Some  of  them  are  known 
to  have  been  defective  at  school  and  can  be  differentiated  from 
ordinary  dull  or  backward  children,  who  in  time  become  normal. 
The  Educational  Medical  Officers  use  the  Binet-Simon  and 
other  tests  to  distinguish  between  them.  Until  the  Mental 
Deficiency  Act  comes  into  operation,  no  means  are  possible 
to  supervise  the  careers  of  the  feeble-minded  who  have 
reached  adolescence.  To  some  extent,  they  are  the  result  of 
bad  parentage,  but  sometimes  they  arise  as  a  natural  variation 
from  a  healthy  stock.  The  majority  belong  to  the  lower  classes 
of  society  and  unfortunately  tend  to  procreate  through  marriage 
or  illegitimacy  to  an  alarming  extent.  Their  progeny  is 
always  unsatisfactory,  as  such  feeble-mindedness  tends  to  be 
transmitted,  or  to  be  transmuted  to  allied  mental  disorders. 
It  is  hoped  that  the  Mental  Deficiency  Act  {vide  p.  275)  will 
lead  to  the  provision  of  approved  homes,  certified  houses,  and 
institutions  for  their  care,  and  thus  prevent  them  from  getting 
into  harm.  Formerly  when  they  left  the  special  schools  at 
the  age  of  sixteen,  no  further  control  was  possible. 


MORAL    DEGENERACY 

Moral  Imbeciles  are  persons  who  from  an  early  age 
display  some  permanent  mental  defect,  coupled  with  strong 
vicious  or  criminal  propensities  on  which  punishment  has 
little  or  no  deterrent  effect. 

In  the  majority  of  cases  of  mental  aberration  affecting 
the  ideational  sphere,  whether  from  congenital  deficiency,  or 
from  acquired  insanity,  the  moral  functions  are  usually  im- 
plicated in  some  degree,  together  with  the  ordinary  emotions 
and  instincts.  This  moral  affection  is  sometimes  particularly 
marked  in  Imbecility  (Moral  Imbecility),  but  it  occurs  also  in 
the  early  stages  of  General  Paralysis,  in  Alcoholism,  Paranoia, 


154  MENTAL   DISEASES 

and  Epilepsy.  Sometimes  also,  moral  failure  is  left  after  a 
patient  has  apparently  recovered  from  an  attack  of  Mania. 
Moral  obliquity  of  an  irresponsible  nature  is  also  sometimes 
present  in  persons  who  are  usually  regarded  as  normal,  or  may 
even  be  associated  with  superior  mental  development,  but  it 
is,  as  a  rule,  associated  with  some  degree  of  Imbecility.  It 
is  then  questionable  how  far  the  conduct  of  these  individuals 
may  be  considered  as  due  to  a  pathological  state,  or  to  be 
dependent  on  inherent  criminal  instincts.  The  border-line  is 
hard  to  define,  and  some  authorities  hesitate  to  admit  of  Moral 
Insanity,  apart  from  other  symptoms  of  mental  disorder. 
The  medical  witness  is  at  times  taunted  with  the  lameness  of 
his  evidence  in  the  defence  of  an  individual,  whom  he  believes 
to  be  defective  in  the  moral  sense,  whose  conduct  brings  him 
into  collision  with  the  law  and  who  yet  displays  no  intellectual 
flaw  or  other  evidence  of  insanity.  The  criminal,  especially 
the  recidivist,  shows  the  same  want  of  moral  obligation,  but 
he  frequently  adopts  his  career,  well  knowing  the  risks,  and 
accepts  these  of  his  own  free  will.  On  the  other  hand,  the 
moral  defective,  whether  he  be  a  thief  or  a  liar,  does  not  possess 
the  same  degree  of  responsibility.  Useless  articles  are  stolen, 
sometimes  of  no  value,  and  he  may  take  no  pains  to  hide  them 
from  others,  or  he  fabricates  statements  and  makes  false 
accusations,  the  full  consequences  of  which  he  does  not  realise. 
Albeit  the  physician  should  approach  such  a  case  with  an  open 
mind,  and  it  is  probable  that  many  so-called  Kleptomaniacs 
are  criminals  of  the  higher  ranks  of  society,  in  which  case 
punishment  is  the  proper  award  for  their  misdoings.  The 
history  should  be  inquired  into.  A  pathological  character  is 
generally  the  result  of  diseased  or  neurotic  parentage,  in  which 
case  mental  and  moral  instability  were  manifest  during  child- 
hood. The  individual  was  perhaps  wayward  and  cruel,  diffi- 
cult to  manage  in  early  life,  precocious  or  late  in  development 
sexually  and  mentally.  A  criminal  has  not  always  this  evolu- 
tionary basis ;  his  vicious  tendencies  break  out  at  adolescence 
or  later,  he  is  often  the  outcome  of  evil  associations  and  he 
does  not  wish  to  earn  an  honest  living.  Punishment  has  some 
remedial  effect  on  his  nature,  whereas  it  hardly  touches  the 
morally  defective  person.  It  is  questionable  what  attitude 
should  be  assumed  towards  the  class  of  sexual  inverts  and 


MORAL   DEGENERACY  155 

perverts.  They  are  certainly  a  menace  to  the  well-being  of 
society  and  should  be  kept  in  seclusion,  if  they  are  unable  to 
control  their  unnatural  instincts,  which  for  the  most  part  are 
congenital  in  origin  and  incurable.  At  present,  they  are  sen- 
tenced by  law  as  criminals  for  a  period,  only  to  return  to 
their  evil  habits  when  at  liberty  again. 

When  a  case  is  once  correctly  diagnosed  as  one  of  moral 
degeneracy,  but  little  improvement  is  to  be  expected.  Its 
proper  management  and  treatment  is  to  be  sought  in  adequate 
supervision  according  to  the  status  in  life,  and  in  the  preven- 
tion of  transmission  of  the  misfortune  to  others  by  pro- 
creation. Moral  imbeciles  can  thus  be  dealt  with  under  the 
Mental  Deficiency  Act. 


CHAPTER   XIII 
DEMENTIA    PRECOX 

Dementia  is  a  condition  of  acquired  weak-mindedness 
in  all  stages  of  gradation,  from  mere  "facility  "  to  a  complete 
absence  of  all  the  higher  mental  functions.  There  is  a  loss  of 
spontaneity^  of  thought,  blunting  of  the  emotional  life,  shallow- 
ness of  will-power,  and  defect  in  conduct.  Above  all,  the 
memory  is  generally  much  involved.  The  term  Dementia  is  used 
for  cases  in  which  the  mind,  having  once  reached  its  proper 
evolution,  has  since  shown  indications  of  Aveakness,  in  con- 
tradistinction to  Amentia,  which  is  an  inborn  or  congenital 
defect. 

Dementia  Prsecox,  or  Precocious  Dementia,  a  term  first 
apphed  by  Pick  of  Prague  in  1898,  comprises  a  group  of 
cases  which  form  about  12  %  of  admissions  to  asylums.  It 
owes  its  differentiation  from  other  tj'pes  of  insanity  largely 
to  the  investigations  of  Kraepelin .  The  recognition  of  a  case 
of  Dementia  Prsecox  in  its  early  stages  is  helpful  as  regards 
prognosis,  and  therefore  merits  the  utmost  consideration.  At 
present,  it  is  not  jet  absolutely  agreed  how  far  the  term 
should  be  applied,  but  the  student  may  content  himself  in 
learning  that  the  vast  majority  of  cases  occur  between  the 
ages  of  fifteen  and  thirtj^-five,  and  are  therefore  included  in  the 
Insanities  of  Adolescence,  which  have  been  so  fully  dealt  with 
by  Clouston.  Yet  it  cannot  be  denied  that  the  symptoms  of 
Dementia  Praecox  do,  on  rare  occasions,  first  manifest  them- 
selves later  in  life,  and  therefore  the  term  cannot  be  used  as 
quite  synonjTXious  with,  those  t3^pes  of  adolescent  insanity  in 
which  the  prognosis  from  the  first  is  bad.  It  is  closely  allied 
to  Imbecility,  from  which,  however,  it  may  be  distinguished 
by  the  history.  The  older  authors  used,  the  term  Primary 
Dementia  to  describe  the  condition,  and  tbis  is  stiU  used  for 

156 


DEMENTIA   PR.ECOX  157 

official  purposes  b}^  the  Commissioners  in  Lunacy.  The 
term  '"'  Schizophrenia  "  has  in  recent  j-ears  also  been  applied 
to  the  disorder.  A  patient  who  is  approaching,  or  has 
reached,  maturity  and  has  possibly  pursued  his  occupation 
in  life  satisfactorily,  occasionally  even  with  brilliancy,  shows 
signs  of  mental  failure  of  a  slowly  progressive  nature.  He 
is  at  times  excited  or  depressed,  becomes  dull,  and  is  lack- 
ing in  social  instincts.  He  loses  all  zest  in  the  healthy 
competition  of  life  and  is  content  to  take  a  back  seat  in 
whatever  he  undertakes.  He  becomes  devoid  of  all  initiative, 
and  is  finally  a  dead  weight  as  regards  his  influence  in  the 
community. 

Etiology. — Dementia  Prsecox  invariably  originates  from 
a  neuropathic  stock.  Only  occasionally  are  there  two  cases 
to  be  found  in  one  family,  and  sometimes  the  other  brothers 
and  sisters  are  above  the  average  in  mental  capacity.  There 
is  often  a  history  of  masturbation,  which,  however,  must  be 
regarded  rather  as  a  s}Tnptom  than  a  cause  of  the  disorder, 
as  is  also  the  statement,  frequently  made,  that  patients  have 
been  seclusive,  and  prone  to  introspective  habits  of  thought. 
The  condition,  as  a  process  of  mental  dissolution,  is  the  grade 
nearest  to  imbeciht}-.  in  some  cases,  an  animal  course  of  life 
has  been  led,  with  but  little  incentive  to  ambition. 

Varieties. — The  symptoms  of  Dementia  Praecox  group 
themselves  under  four  main  forms,  although  it  must  be  granted 
that  these  forms  frequently  merge  into  one  another.  It  is ,  ho\v- 
ever,  useful  clinically  to  distinguish  them,  viz.  : 

(1)  Simple  Dementia  Prsecox, 

(2)  Hebephrenia, 

(3)  Katatonia, 

(4)  Dementia  Paranoides. 

Simple  Dementia  Praecox. — In  this  variety,  the  patients 
live,  as  it  were,  on  a  lower  plane  of  activity  which,  in  an  extreme 
measure,  betokens  a  purely-  vegetative  life.  Their  movements 
are  clumsy,  motor  characteristics  being,  for  the  most  part, 
latent.  They  may  eat  and  sleep  well,  but  they  are  not 
capable  of  doing  much  work.  The  association  neurons  have 
become  disconnected,  so  that  ideation  is  retarded,  or  dis- 
turbed.    Their  thoughts  are  circumscribed,  and  delusions  may 


158  MEXTAL   DISEASES 

often  be  present.  They  e'vince  but  little  feeling,  although 
they  may  easity  be  roused  into  a  state  of  angn^  passion  or 
inordinate  laughter,  inasmuch  as  their  self-control  is  weakened. 
Masturbation  is  frequent.  Memory  is  sometimes  defective, 
especially  in  the  recollection  of  proper  names.  All  recently 
acquired  knowledge  is  apt  to  be  forgotten.  Many  cases  remain 
in  a  condition  of  Partial  Dementia  which  has  not  progressed 
further.  The  general  appearance  of  the  countenance  shows  a 
want  of  expression.  Patients  are  untidy  and  sometimes  dirty 
in  their  general  habits.  The  reflexes  are  slow,  and  there  is 
some  tendenc}^  to  slight  general  anaesthesia. 

Hebephrenia  (rj^T],  puberty;  fpQ7]v,  the  mind),  which 
owes  its  designation  to  Kahlbaum,  is  characterised  by  mental 
depression,  apathy,  and  incapacity  for  work.  There  are 
intervals  in  which  the  patient  is  restless  and  wanders  about 
aimlessly,  the  depression  being  replaced  by  contentment  and 
laughter.  He  usually  shmis  the  society  of  others,  is  untidy, 
and  lounges  about  in  comfortable  armchairs,  doing  nothing. 
Hallucinations  are  frequent,  and  mental  deterioration  is,  as  a 
rule,  progressive  until  Dementia  is  fully  estabhshed.  Some- 
times, definite  persecutor}^  delusions  arise,  and  the  Hebephrenic 
develops  into  a  case  of  Dementia  Paranoides. 

Katatonia  (xajd,  down ;  xovog,  tension),  to  stretch  or  strain 
oneself,  a  word  also  coined  by  Kahlbaum,  who  first  described 
its  depressed  form  in  1872.  There  is  uniform  rigidity  of  the 
muscular  sj^stem.  The  patient  is  usually  mute  and  resistive, 
exhibiting  a  condition  of  obstinacy  and  perverseness.  He  often 
repeats  a  sentence  over  and  over  again  and  exhibits  pecuHar 
stereotj'ped  mannerisms.  Sometimes  a  patient  ma}^  be  quite 
apathetic,  and  shows  but  little  sign  of  mentation,  the  con- 
dition is  then  styled  Katatonic  Stupor,  but  consciousness 
is  not  really  affected  in  the  earh^  stage  of  the  disorder.  He 
sometimes  neither  speaks  nor  moves,  but  ynW  allow  his  limbs 
to  assume  any  position  in  which  they  may  be  placed  bj^  an 
observer  {Catalepsy  or  flexibilitas  cerea).  The  condition  may 
pass  into  a  state  of  excitement,  the  patient  making  grimaces 
and  gesticulating.  He  is  frequently  impulsive,  destructive 
and  dirt}^  in  his  habits,  and  incoherent  in  speech.  Hallucina- 
tions are  common. 

Dementia  Paranoides  is  the  term  applied  to  those  cases 


de:mentia  precox 


Fig.   39. — Dementia  Prcecos  (Katatonia). 


160  MENTAL  DISEASES 

in  which  delusions  of  persecutions  are  uppermost.  The}'  are 
often  also  exalted  in  their  ideas,  and  they  have  marked  hallucina- 
tions which  vary  from  time  to  time,  and  correspond  with  the 
delusions.  Aural  hallucinations  are  most  usual,  but  all  the 
senses  may  be  affected.  Visual  aberration  is  rare.  Many 
patients  complain  of  electrical  currents  affecting  them  and 
others  are  full  of  insane  suspicions.  In  the  course  of  time,  as 
the  Dementia  increases,  mannerisms  and  careless  habits  be- 
come manifest.  This  variety  is  sometimes  superimposed  on 
the  Hebephrenic  form. 

Physical  Signs. — In  the  early  stages  of  Dementia  Praecox 
the  patient  is  in  indifferent  health,  with  a  sallow  complexion 
and  a  poor  pulse.  The  hair  tends  to  stand  on  end,  and  Stoddart 
has  pointed  out  that  there  is  frequently  complete  transverse 
wrinkling  on  the  forehead.  The  deep  reflexes  are  notabty 
exaggerated.  Patients  take  their  food  well,  as  a  rule,  and  in 
time  tend  to  improve  physically  and  even  to  become  fat.  Li 
the  Katatonic  varietj^,  the  hands  and  feet  are  frequently 
swollen  and  blue,  and  there  is  oedema  about  the  face.  The 
Paranoidal  cases  do  not,  as  a  rule,  show  much  physical  disorder. 

Mental  Symptoms. — At  the  outset  of  the  disorder,  sensa- 
tion is  certainly  affected  in  many  cases  of  Hebephrenia  and 
Katatonia,  but  whether  a  true  anaesthesia  exists,  is  doubtful. 
The  patient  sometimes  seems  to  take  no  heed  of  impressions  of 
which,  when  he  improves  for  a  time,  he  asserts  he  was  iuWy 
conscious.  Similarly,  perception  and  ideas  of  place  and  time 
are  not  lost,  but  hallucinations,  especially  aural,  exist.  Memory, 
likewise,  is  scarcely  affected  at  first,  and  the  patient's  insight 
into  his  condition  is  sometimes  present.  The  patient  is 
apathetic  as  to  his  state  and  his  surroundings,  but  he  exhibits 
markedly  a  condition  called  Negativism,  i.  e.  he  carries  out  an 
action  exactly  opposite  to  what  is  requested.  He  is  not  sug- 
gestible and  frequently  becomes  resistive,  and  refuses  to  dress 
or  undress.  Mutism,  which  is  so  often  present,  is  also  due  to 
the  negativistic  spirit,  and  when  the  silence  is  broken  he  may 
utter  a  string  of  words  over  and  over  again  (Verbigeration), 
or  he  repeats  what  he  has  just  heard  {Echolalia),  or  again  he 
imitates  the  gestures  of  others  (Echopraxia).  A  patient  develops 
peculiar  Mannerisms,  e.g.,  touching  things  as  he  passes,  or 
standing  on  one  leg,  and  when  such  tricks  or  gesticulations  are 


DEMENTIA  PII.ECOX 


161 


Fig.  31. — Dementia  Prsecox  (flexibilitas  cerea). 


162  MENTAL  DISEASES 

constantly  repeated,  the  condition  is  called  Stereotypy.  One 
frequently  sees  a  patient  walking  on  one  line  in  a  strained 
attitude  along  the  same  patch  of  grass.  The  patient,  although 
conscious  of  his  environment,  does  not  appear  to  assimilate 
impressions,  and  there  is  a  gradual  decline  in  the  thought 
processes  as  the  Dementia  progresses.  Delusions  usually 
appear  in  Dementia  Praecox ;  th.ej  are  most  pronounced  in 
the  Paranoidal  variety,  and  the  patient  may  become  talkative, 
and  he  may  write  many  letters.  He  is  defective  in  emotional 
reaction,  being  rarely  very  depressed  or  very  excited.  He  shuns 
the  company  of  other  patients  and  generally  tries  to  hide  away 
from  the  doctor  on  his  regular  rounds  of  visitation.  Very  rarel}' 
does  he  evince  any  homicidal  tendencies,  but  occasionally  a 
Paranoidal  case  may  become  dangerous  on  account  of  his 
delusions . 

Diagnosis. — The  disease  is  one  beginning  principal^  during 
adolescence,  but  it  maj^  also  develop  later  in  life.  It  must  be 
distinguished  from  Imbecilitj^,  which  is  a  condition  of  mental 
weakness  from  birth.  The  history  of  gradual  and  insidious 
development  of  signs  of  insanity  should  be  helpful  in  diagnosing 
a  case  of  Dementia  Praecox  from  Maniacal-Depressive  insanity 
or  Confusional  insanity,  apart  from  the  characteristic  symptoms 
of  negativism,  verbigeration,  stereotypy,  etc.  Phj'sical  signs 
of  General  Paralysis,  after  Congenital  or  Acquired  SyphUis,  as 
well  as  those  of  other  Organic  Brain  Disease,  should  always  be 
looked  for.  The  Paranoidal  form  resembles  Paranoia  to  some 
extent ;  hallucinations  occur  in  both,  but  in  Paranoia  the  delu- 
sions are  more  persistent  and  systematised,  and  the  tendency  to 
Dementia  is  but  small,  whilst  the  mannerisms  are  also  absent. 

Prognosis. — A  fair  proportion  of  dements  in  asylums 
consist  of  cases  that  began  with  sjonptoms  of  Dementia  Praecox. 
It  is  not  too  much  to  say  that  80  %  of  cases  of  the  disease 
never  recover  sufficiently  to  earn  a  livelihood.  Of  the  remaining 
20  %,  in  some  there  is  an  arrest  of  the  disease  for  a  time,  these 
cases  being  regarded  as  cures,  others  may  become  partially 
demented  only,  and  others  again  develop  Phthisis.  The 
Paranoidal  form  is  most  chronic  in  its  development.  Dementia 
being  almost  certain  to  supervene  in  the  course  of  time.  Kata- 
tonia  has  a  somewhat  better  outlook  than  has  Hebephrenia. 

Pathology. — Nothing  distinctive,  so  far,  has  been  described 


DEMENTIA   PRiECOX   -  163 

to  account  for  this  disorder.  It  lias  been  suggested  that  it 
may  be  due  to  auto-intoxication,  possibly  from  internal  secre- 
tions of  the  sexual  organs,  in  persons  of  degenerative  stock. 
The  brain  convolutions  are  sometimes  found  irregular,  and 
gliosis  of  the  deepest  laj^er  of  the  cortex  has  been  described. 
This  assertion  has  led  to  the  hypothesis  that  a  pathological 
dissociation  is  thereby  induced  between  the  afferent  and  efferent 
neurons  of  the  brain.  Some  of  the  nerve  cells  are  described 
as  immature.  In  advanced  cases  there  is  the  usual  micro- 
scopical appearance  of  a  cortex  from  a  case  of  Dementia  ^^ith 
total  destruction  of  nerve  cells. 

Treatment. — Unless  the  patient  is  very  well  off,  it  is  usually 
wisest  to  send  him  to  an  institution.  Supervision  under  a 
companion  or  medical  attendant  may  suffice  in  early  cases 
and  during  remissions,  but  when  mutism  and  negativism  are 
marked,  the  patient  ought  to  leave  home.  All  bad  habits 
must  be  corrected,  and  the  patient  should  be  encouraged  to 
occupy  his  time  usefully.  The  physical  health  must  be  im- 
proved by  nutritious  food  and  tonics .  Bed  treatment  is  usually 
indicated  in  the  Katatonic  cases.  Rarely  are  psycho -analytical 
measures  available  as  therapeutic  agencies. 


SECONDARY   DEMENTIA 

This  is  the  chronic  state  of  weak-mindedness  frequently 
called  Terminal  Dementia,  which  is  answerable  for  so  large 
a  proportion  of  the  chronic  inmates  of  asylums.  It  occurs 
in  all  degrees,  from  mere  stupidity  or  apathy  of  mind  with 
restless  movements,  to  an  apparent!}^  total  absence  of  the 
mental  functions  when,  in  extreme  cases,  the  patient  is  re- 
duced to  the  lowest  level  of  animal  life.  The  mental  dissolution 
may  be  general  or  partial,  and  in  the  latter  case  the  term 
Partial  Dementia  is  often  used.  The  condition  is  called 
Secondary  because  it  supervenes  on  other  attacks  of  insanity- 
It  has  been  said  that  all  insanities  tend  to  some  degree  of 
Dementia,  and  that  the  excitement  or  depression  in  a  given 
case  is  only  a  phase  in  the  process  of  Dementia,  which  is  to 
some  extent  present  throughout.     On  the  other  hand   it  must 


164  MENTAL  DISEASES 

be  acknowledged  that  many  persons  recover  from  first  attacks 
of  insanity  completely.  It  must  be  understood  that  Secondary 
Dementia  is  not  a  distinctive  entity,  confined  to  Maniacal- 
Depressive  disorder  of  an  incurable  type,  but  the  last  stage 
of  various  insanities,  its  origin  being  occasionally  traced  easily 
in  any  particular  case.  Secondary  Dementia  is  an  incurable 
state  which  lasts  so  long  as  the  patient  lives. 

Etiology. — A  history  of  neuropathic  stock  is  usually,  but 
not  by  any  means  always,  elicited.  The  Dementia  occurs 
as  a  result  of  a  severe  attack  of  (Intermittent)  Maniacal- 
Depressive,  or  of  Confusional  insanity,  or  from  repeated  milder 
attacks  of  these  disorders.  It  also  takes  place  as  the  terminal 
stage  of  iVlcoholic,  Epileptic,  and  other  insanities.  It  may  be 
regarded  as  a  part-process  of  General  Paralysis. 

Mental  Symptoms. — The  patient  shows  a  want  of  interest 
in  his  surroundings  and  fails  to  take  in  impressions.  Per- 
ception is  disordered,  and  in  profound  cases  it  may  be  quite 
absent.  The  patient's  memory  is  much  impaired  or  it  may 
be  absent  altogether,  and  his  ideas  of  time  are  confused  or 
lost.  He  is  unable  to  converse  with  any  intelligence  or  he  may 
be  perfectly  incoherent,  with  remnants  of  delusions  and  hallu- 
cinations. He  takes  no  notice  of  family  news  given  to  him. 
His  feelings  and  emotions  are  deadened.  At  times  he  has 
outbursts  of  noisy  excitement,  and  he  may  be  impulsively 
violent,  but  the  attacks  of  passion  are  usually  short,  and  suicidal 
impulses  are  rare.  His  instincts  are  affected,  he  is  apt  to 
bolt  his  food  voraciously,  whilst  other  cases  need  hand- 
feeding.  The  sexual  passion  is  sometimes  dormant,  but, 
when  active,  it  gets  out  of  control,  and  masturbation  is  fre- 
quent. Bad  cases  become  wet  and  dirty,  and  the  habits  may 
be  filthy.  Patients  tend  to  collect  rubbish  in  their  pockets 
and  to  put  refuse  into  their  mouths,  or  even  to  swallow 
stones,  if  not  watched.  Their  actions  are  degraded,  they 
are  untidy,  and  destructive  to  their  clothing  and  to  articles 
of  furniture,  and  pay  but  little  heed  to  the  calls  of  nature, 
unless  trained  by  nurses. 

A  secondary  dement  in  time  automatically  conforms  him- 
self to  the  discipline  of  an  institution.  He  is  difficult  to 
keep  clean  or  neat,  and  he  cannot  adapt  himself  to  the  environ- 
ment of  everyday  family  life. 


SECONDARY   DEMENTIA  165 

Physical  Signs. — The  expression  of  the  face  becomes 
vacant.  The  circulation  is,  as  a  rule,  feeble.  Nutrition  is 
variable,  some  cases  being  very  thin,  and  others  plump  or  even 
fat,  with  a  greasy  skin  and  a  tendency  to  eruptions.  The 
attitude  and  gait  are  slouching,  and  therefore  there  is  a  tendency 
to  lung  affections,  especially  Phthisis.  The  majorit}^  of  these 
patients  usually  sleep  a  good  deal. 

Diagnosis. — This  must  be  made  from  Stupor,  which  is  only 
a  temporary  cessation  of  the  mental  functions,  and  from  special 
varieties  of  Dementia,  by  the  history  and  bodity  signs,  e.  g. 
cases  of  Dementia  Preecox  usually  show  some  indications  of 
stereotj'ped  movements  and  mannerisms,  etc. 

Prognosis. — No  case  of  pronomiced  Secondary  Dementia 
ever  recovers,  although  apparent  improvement  under  routine 
treatment  is  frequently  observed  in  many  patients.  Secondary 
dements  with  proper  care,  therefore,  live  for  years,  though 
they  are  more  prone  to  intercurrent  maladies  than  are  normal 
people. 

Pathology. — The  brain  shows  degenerative  changes  with 
destruction  of  nerve  cells  and  nerve  fibres,  together  with 
increase  in  the  neuroglial  elements.  Some  excess  of  cerebro- 
spinal fluid  is  present  if  wasting  is  pronounced.  Vascular 
changes  may  be  found.  The  membranes  are  usually  thickened 
and  opaque,  and  the  skull  cap  may  be  dense,  and  msjy  show 
calcareous  plates.  Eatt}"  degeneration  in  the  visceral  organs 
is  frequent. 

Treatment. — This  consists  in  careful  and  regular  manage- 
ment. The  patient  should  be  properly  dieted ;  some  dements  eat 
enormously,  whilst  others  have  to  be  spoon-fed.  The  bowels 
must  be  attended  to  in  order  to  obviate  either  diarrhoea  or 
constipation.  It  is  customary  to  give  most  of  these  patients 
a  laxative  once  a  week  and  to  train  them  to  regular  habits. 
Exercise  in  the  open  air  is  necessary,  and  perfect  hygiene 
should  be  maintained.  Manj-  of  the  milder  cases  can  be  made 
useful  and  happy  under  supervision  in  institutions  by  some 
occupation,  such  as  employment  in  the  workshops  or  laundries, 
or  by  work  in  the  garden  or  on  the  \suw\\ .  All  possible  means 
should  be  adopted  to  correct  bad  habits.  In  bed-ridden  and 
advanced  cases,  absolute  cleanliness  should  be  maintained  to 
prevent   bed-sores.     A   dement   should  never  be  allowed   to 


166  MENTAL   DISEASES 

transact  a^nj  business.     If  he  has  any  mind  left   at  all,  he 
would  sign  away  anything,  if  capable  of  writing. 


ORGANIC    DEMENTIA 

This  is  a  condition  of  loss  of  the  mental  faculties  due  to 
some  obvious  lesion  of  the  brain,  localised  or  diffuse.  Patients 
are  usually  in  middle  or  advanced  life,  and  although  the 
main  feature  is  that  of  chronic  weak-mindedness  and  apath}^, 
there  is  also  from  time  to  time  restlessness,  irritability  with 
delirium,  excitement,  or  depression,  rendering  them  difficult 
to  be  managed.  The  majority  of  cases  have  Arterio-sclerosis  or 
some  vascular  lesion  of  the  brain  which  has  left  possibly 
Hemiplegia  or  Aphasia  with  marked  mental  symptoms.  Cere- 
bral thrombosis,  usually  Syphilitic  but  occasionally  of  Septic 
or  of  other  origin,  or  embolism  or  haemorrhage  may  be  the 
cause  of  the  trouble  ;  or  the  condition  may  be  due  to  a  Tumour, 
a  Gumma,  or  rarely  to  Abscess  or  Meningeal  inflammation, 
Syphilitic,  Tubercular,  Traumatic,  or  otherwise.  The  student 
should  refer  to  the  textbooks  on  general  Medicine  for  the 
differential  diagnosis  of  Gross  Brain  Disease.  The  eyes  should 
always  be  examined  for  signs  of  optic  neuritis,  etc. 

Symptoms. — The  mental  deterioration  in  these  cases  is 
usually  progressive,  with  marked  loss  of  memory.  There  is 
mental  confusion,  both  as  to  time  and  place,  with  delusions 
of  identity,  and  general  childishness.  The  special  senses  are 
dulled  and  sometimes  disordered,  and  the  patients  are  liable  to 
lethargy  and  somnolence.  There  is  a  lack  of  spontaneity 
in  thought  and  action.  The  speech  is  slow  and  often  in- 
distinct, owing  to  paralytic  or  aphasic  defect,  or  there  may 
be  absolute  incoherence.  Headache  is  sometimes  complained 
of,  and  sleeplessness  may  be  the  result.  The  patient's  habits 
degenerate,  leading  in  some  cases  to  acts  which  may  bring 
him  into  contact  with  the  police.  Some  of  the  symptoms 
appear  to  be  due  to  alteration  in  arterial  tension,  with  dis- 
turbance of  pressure  of  the  cerebrospinal  fluid.  Witselsucht, 
i.  e.  an  undue  tendency  to  jesting,  often  occurs. 

Diagnosis. — Occasional  mistakes  have  been  made  in  dis- 


ORGANIC   DEMENTIA  167 

tinguishing  Organic  Dementia  from  General  Paralysis,  Uraemia, 
and  even  Hysteria ;  but  a  careful  physical  examination  should 
render  the  diagnosis  clear. 

Prognosis. — ^As  regards  mental  recovery,  this  is  generally 
bad,  but  some  Syphilitic  cases  improve  although  but  few  are 
cured.  The  nature  of  the  lesion  present  wall  be  the  best 
means  of  estimating  the  patient's  length  of  life. 

Treatment. — This  must  be  conducted  on  general  lines,  and 
it  is  only  occasionally  necessary  that  a  patient  should  be  certi- 
fied, and  removed  from  home  surroundings.  In  some  cases  of 
cerebral  softening  due  to  specific  disease.  Mercury  and  Iodides, 
or  Salvarsan  should  be  given.  Any  localising  signs  should  be 
carefully  noted  in  cases  suspected  of  new  growth,  the  possibility 
of  surgical  interference  being  borne  in  mind.  Lumbar  puncture 
has  relieved  some  cases  due  to  Meningitis. 


SENILE    DEMENTIA 

The  approach  of  Senility  is  accompanied  by  a  certain 
amount  of  sluggishness  of  the  bodily  and  mental  functions, 
which  deteriorate  side  by  side,  and  this  deterioration  must 
be  regarded  as  physiological.  The  outlook  on  life,  in  general, 
tends  to  be  less  hopeful.  Depression  and  irritability  are 
therefore  common,  whilst  in  predisposed  persons  genuine 
attacks  of  intermittent  Mania  or  Melancholia  may  occur. 
These  attacks,  if  not  ending  in  recovery,  may  lead  to  the 
establishment  of  Dementia ;  but  the  condition  is  one  mostly 
met  with  as  a  result  of  a  gradual  progressive  mental  weakness 
in  excess  of  the  decay  of  the  general  physical  processes,  and 
accounts  for  as  much  as  11|  %  of  insanity. 

Etiology. — From  sixty-five  upwards  is  the  age  when  mental 
dechne  usually  begins  in  these  cases,  but  occasionally  as  a 
result  of  precedent  Syphilis,  or  Alcoholism,  with  arterial  de- 
generation, the  mental  dissolution  begins  at  an  earlier  date 
(Pre-senile  Cortical  Atrophy).  The  patient  may  have  had 
to  give  up  his  former  occupations,  or  he  has  retired  of 
his  own  accord,  and  it  would  appear  that  frequently,  the 
necessary    stimuli    for   the    proper   maintenance    of  healthy 


168  MENTAL   DISEASES 

mental  life  having  been  cut  off,  the  patient  drifts  into  a  state 
which  augments  the  progress  of  the  disorder. 

Physical  Signs. — The  history  is  usually  one  of  loss  of 
weight.  The  muscles  are  fiabb}^  and  weak,  the  reflexes  are 
diminished,  and  the  bones  become  brittle.  The  forehead  is 
wrinkled,  the  teeth  are  loose,  decayed  or  absent.  Arcus 
senilis  may  be  present,  wdth  lustreless  eyes.  The  vision  is 
usually  impaired,  deafness  is  frequent,  and  in  fact  all  the 
special  senses  are  dulled.  The  abdomen  is  flaccid,  the 
liver  sluggish,  and  irregular  action  of  the  bowels  is  common. 
Micturition  is  frequent,  this  being  usually  due  to  prostatic 
enlargement . 

Mental  Symptoms.- — The  patient  becomes  peevish  and 
irritable,  has  attacks  of  ill-temper  and  is  quarrelsome.  He 
mislays  his  belongings,  becomes  suspicious,  and  accuses  others 
of  purloining  his  property".  He  is  therefore  prone  to  hide  his 
money  and  articles  of  value.  In  the  early  stages  he  may 
complain  of  headache  and  sleeplessness.  He  usually  drops 
off  to  sleep  during  portions  of  the  daytime,  and  then  becomes 
restless  at  night,  often  refusing  to  go  to  bed  at  all,  or  rising 
early  in  the  morning.  His  memory  is  affected ;  at  first  he 
forgets  perhaps  proper  names  only,  then  ordinary  present 
events,  until  finally  he  remembers  only  the  facts  of  his  earlier 
years.  His  perception  is  disordered ;  in  profound  cases  he 
mistakes  the  identity  of  those  about  him,  and  fails  to  recognise 
even  his  relatives.  Fleeting  delusions  occur,  especially  in  the 
latter  part  of  the  day  and  during  the  night.  Patients  at  times 
become  noisy,  and  accuse  others  of  assaulting  them.  As  the 
disease  progresses,  the  memory  is  quite  obliterated,  and  incoher- 
ence is  absolute,  so  that  speech  is  unintelligible.  The  primary 
instincts  become  affected,  but  not  always  quite  regularly ;  the 
sexual  function  is  frequently  hyperactive  and  is  not  under 
control,  possibty  owing  to  prostatic  irritation.  Senile  cases, 
therefore,  become  at  times  the  subject  of  inquiry  at  pohce 
courts. 

Diagnosis. — Senile  Dementia  is  so  far  characteristic,  but 
in  its  milder  forms  it  resembles  ordinary  Senility,  from  which 
it  differs  only  in  degree.  The  age  of  the  patient  and  the  failure 
of  memory  should  especially  help  to  distinguish  it  from  other 
insanities. 


SENILE   DEMENTIA    ,  169 

Prognosis. — There  is  little  hope  of  improvement  or  of 
arrest  of  the  condition,  which  progresses  mitil  the  patient's  vital 
organs  are  exhausted.  The  average  duration  of  these  cases 
is  about  five  years,  although  some  last  longer,  and  others 
succumb  after  a  few  months. 

Pathology. — The  skull,  although  occasionally  thinner  than 
normal,  is  not  infrequently  thickened,  and  the  dura  becomes 
adherent.  The  Pacchionian  bodies  are  enlarged,  and  the  pia 
arachnoid  has  a  milky  and  opaque  appearance.  The  brain  is 
shrunken  in  bulk,  owing  principally  to  atrophy  of  the  grey 
matter  of  the  convolutions,  which  is  most  marked  in  the  frontal 
region.  There  is  complementary  increase  in  the  amount  of 
cerebro -spinal  fluid.  Microscopically  there  is  extensive  destruc- 
tion of  the  nerve  elements  with  proliferation  of  the  neurogha. 
Some  of  the  nerve  cells  are  atrophied,  which  in  certain  cases  is 
the  primary  condition  (Presbyophrenia),  in  others  it  is  probably 
secondary  to  vascular  affection,  the  blood  vessels  being  sclerosed 
from  Renal  or  Sj^hihtic  disease  (Arteriopathic  Dementia). 
Locahsed  softenings  are  commonly  found.  The  visceral 
organs  indicate  degenerative  changes,  and  the  bones  are  atro- 
phied. It  has  been  suggested  as  an  explanation  of  the  loss 
of  vitahty,  degeneration  and  decay  in  old  age,  that  the  cortical 
atrophy  on  which  Senility  depends  is  due  to  auto-intoxication. 
This  may  be  due  to  defective  metabolic  processes  of  the  tissues 
leading  to  a  diminution  in  intensity  of  afferent  impressions  from 
the  viscera  in  particular,  the  brain  being  thus  deprived  of  its 
former  organic  stimuli  upon  which  mental  activity  so  largely 
depends. 

Treatment. — This  resolves  itself  into  the  most  careful 
supervision  and  nursing.  In  no  case  can  the  tact  and  patience 
of  a  nurse  be  so  much  put  to  the  test  as  in  that  of  a  restless 
Senile  Dement.  On  sentimental  grounds  it  is  best  to  strain 
an  effort  to  keep  the  patient  at  home,  making  use  of  certificates 
only  if  active  control  or  interference  is  imperative.  It  is  in  time 
realised,  however,  in  most  cases  that  a  separation  from  rela- 
tives and  home  influences  is  best,  and  that  these  patients 
are  happier  in  a  small  institution  where  every  comfort  can  be 
obtained,  and  where  there  is  scope  for  their  activities.  To 
allay  the  nocturnal  restlessness  Veronal  gr.  v.  to  gr.  x.  maj^ 
be  given  in  hot  milk  before  retiring  to  bed,  or  Sulphonal  gr.  xv. 


170  MENTAL   DISEASES 

may  be  prescribed.  Frequently  some  milk  and  biscuits  will  calm 
the  patient  during  the  night.  Alcohol  is  sometimes  indicated, 
especially  at  bedtime  to  assist  in  producing  sleep.  Gentle 
exercise  in  the  open  air  during  the  day,  with  a  proper  regulation 
of  diet  is  all  that  can  be  done  for  the  patient,  who  in  time 
becomes  a  bed-ridden  invalid  and  needs  the  most  careful 
nursing.  The  bladder  and  rectum  require  close  attention. 
Care  should  be  taken  that  the  patient  does  not  trip  up  or  fall, 
especially  as  the  bones  are  fragile,  and  easily  fracture. 


CHAPTER   XIV 
GENERAL    PARALYSIS    (DEMENTIA    PARALYTICA) 

This  disease  is  frequently  termed  General  Paresis,  Pro- 
gressive Paralysis,  and  Paralytic  Dementia.  The  main  feature 
of  the  condition  consists  in  a  gradual  weakening  of  the  mind 
and  body,  tending  to  Paralysis  and  Dementia,  and  ending 
fatally  in  the  course  of  two  or  three  years.  The  pathological 
anatomy  of  this  disease  has  done  much  to  demonstrate  the 
connexion  between  mind  and  body.  It  may  indeed  be  con- 
sidered the  essential  link  between  Mental  diseases  and  general 
Medicine,  in  spite  of  any  scepticism  concerning  this  relation- 
ship. To  a  former  Superintendent  of  Bethlem — Dr.  Haslam — 
belongs  the  distinction  of  first  drawing  attention  to  the  dis- 
ease, in  1798,  but  it  was  not  fully  accepted  or  described  until 
Dr.  Bayle,  a  French  physician,  wrote  his  monograph  in  1829. 
Esquirol  had  also  pointed  out  that  insanity  associated  with 
difficulty  in  speech  was  Invariably  fatal.  General  Paralysis 
accounts  for  about  one-sixth  of  the  total  number  of  deaths 
in  asylums.  Whatever  its  incidence  has  been  in  the  past, 
it  appears  to  have  been  on  the  increase  of  late,  and  it  now 
forms  about  9  %  of  admissions  to  all  asylums  and  considerably 
more  in  some  than  in  others.  In  the  London  County  asylums 
it  forms  about  16%  of  the  male  admissions. 

Etiology. — Of  all  the  causes  to  which  this  disease  has  been 
attributed,  Syphilis  is  undoubtedly  the  outstanding  factor.  It 
is  indeed  not  too  bold  to  state  that  an  individual  who  has  not 
inherited  or  acquired  Syphilis  is  immune  from  General  Paralysis. 
There  is  no  authentic  record  of  any  disease  resembling  General 
Paralysis  amongst  the  Ancients.  It  probably  existed  in  Shake- 
speare's time  (e.  g.  Troilus  and  Cressida,  Act  II,  sc.  iii,  lines 
165-175).  It  is  to  be  noted  that  Syphilis,  which  was  endemic 
in  Naples  in  1494,  spread  to  France  later  on,  and  was  imported 

171 


172  MENTAL   DISEASES 

thence  to  England.  The  syphilitic  origin  of  General  Paralysis 
was  first  suspected  in  1857,  but  it  is  only  in  recent  years  that 
it  has  been  universally  accepted.  A  history  of  Syphilis  is 
usually  admitted  in  75%  of  cases,  and  in  a  variable  pro- 
portion of  the  remainder  evidence  of  the  infection  can  be 
detected.  Patients  frequently  mislead  the  physician  wilfully 
as  to  their  past,  whilst  many  do  not  know  that  they  have 
ever  contracted  the  disease.  The  primary  chancre  may  have 
been  unnoticed,  and  the  secondaries  may  have  been  too  slight 
for  recognition.  It  is,  moreover,  probable  that  the  virus- 
producing  organism,  a  spirochete — the  treponema  pallidum — 
affects  the  nervous  system  rather  than  the  mesoblastic  tissues. 
The  condition  has  been  regarded  as  a  Para-Syphilitic  disease 
and  develops  on  an  average  ten  years  after  infection,  but  it 
may  arise  as  early  as  five  years  or  as  late  as  twenty  years  after 
the  disease  has  been  contracted.  That  Syphilis  alone  cannot 
produce  the  disease  is  manifest  from  the  comparative  rarity  of 
General  Paralysis  in  persons  who  have  been  subject  to  specific 
infection.  It  has  been  computed  that  4  %  of  such  persons  who 
at  one  time  or  another  have  suffered  from  Syphilis  ultimately 
develop  General  Paralysis  or  Tabes.  In  the  juvenile  form  of  the 
former  disease,  evidence  of  Congenital  Syphilis  can  practically 
always  be  obtained.  It  must  be  borne  in  mind  that  syphilitic 
persons  develop  other  varieties  of  insanity  besides  this  disease, 
and  that  occasionally  a  General  Paralytic  has  a  history  of 
a  former  curable  attack  of  insanity.  From  an  analogy  with 
Tuberculosis  it  has  been  suggested  that  there  is  a  particular 
diathesis  associated  with  this  disease.  Some  cases  of  Primary 
Dementia  begin  with  a  precociousness  which  flickers  out  early, 
and  they  settle  down  to  a  permanent  vegetative  existence, 
so  that  it  has  been  hinted  that  General  Paralysis  is  but  a  fatal 
form  of  Para-Syphilis  superimposed  on  this  condition :  in 
other  words,  that  the  Primary  Dementia  would  have  become 
manifest  had  the  patient  escaped  luetic  infection.  The 
patient's  history,  however,  often  is  that  he  was  previously 
above,  rather  than  below,  the  average  in  physical  health  and 
brain  power,  full-blooded  with  a  sanguine  temperament,  am- 
bitious, keen,  hard-working,  and  anxious  to  make  the  most  of 
life.  Full  of  interests,  and  with  no  lack  of  self-confidence,  he 
makes  his  way  amongst  his  fellow  men.     Fond  of  society,  of 


GENERAL  PARALYSIS  173 

good  food  and  of  the  glass  that  cheers  but  at  times  inebriates, 
a  persona  grata  with  the  opposite  sex,  he  marries  early  in  life, 
or  forms  an  illicit  connexion .  Such  is  the  frequent  type  of  person 
that  forms  the  soil  for  the  development  of  General  Paralysis  : 
other  contributory  causes  are  sexual  excess,  undue  stimula- 
tion by  alcohol  and  by  nitrogenous  diet.  Overwork,  and  the 
excitements  and  anxieties  appertaining  to  certain  classes  of 
civilised  life,  also  plaj-  a  part  in  the  production  of  the  disorder. 
Its  occurrence  is  infrequent  in  rural  districts.  The  disease 
has  indeed  been  aptly  described  by  Krafft-Ebing  as  due  to 
"  Civilisation  and  Syphilisation . "  Occasionall}^  there  is,  before 
the  outbreak,  a  recent  history  of  a  cerebral  injury,  of  shock, 
of  sunstroke,  or  of  an  attack  of  influenza,  which  has  precipitated 
the  disease  in  the  process  of  its  evolution.  Ford  Robertson 
has  described  a  diphtheroid  organism,  the  Bacillus  paralj^ticans, 
which  he  suggests  invades  the  cerebral  tissues  and  cerebro- 
spinal fluid  from  the  mouth  and  nostrils,  producing  toxins 
weakening  the  defences  of  the  nervous  tissue.  Sufficient 
proof,  however,  of  its  influence  in  the  causation  of  the  disease 
is  still  wanting. 

In  General  Paralysis  hereditary  taint  is  not  marked.  Very 
rarely  is  there  a  history  of  the  same  disease  in  the  parents. 
In  10%  only  of  cases  can  Insanity,  Epilepsy,  or  Cerebral 
affections  be  traced  in  the  immediate  ancestors.  Occasionally 
two  brothers  exhibit  the  disease,  and  cases  of  husband  and 
wife  have  been  recorded  (Conjugal  General  Paralysis). 

Sex. — The  disease  is  much  more  common  in  males  than  in 
females ;  especially  is  this  so  in  the  upper  classes.  The  ratio 
corresponds  with  the  incidence  of  Syphilis. 

Age. — The  majority  of  cases  occur  between  thirty-five  and 
fifty,  but  some  are  recorded  as  early  as  twenty-five  and  as  late 
as  sixty-two.  The  Juvenile  or  Congenital  cases  develop  about 
the  age  of  twenty,  or  before. 

Civil  State. — The  preponderance  of  cases  in  the  acquired 
disease  is  undoubtedly  amongst  married  men. 

Occupation. — It  affects  all  classes.  It  is  perhaps  least  seen 
in  the  Clergy,  and  most  in  the  Army. 

Premonitory  Indications. — The  disease  rarely  sets  in  with- 
out some  warning.  Change  of  disposition  is  usually  noticed. 
The  patient  may  become  moody  and  reticent,  loose  in  his 


174 


MENTAL   DISEASES 


morals,  restless,  and  unable  to  give  the  former  attention 
to  his  work.  Hypochondriacal  feelings  may  ensue,  and  the 
doctor  is  accordingly  consulted,  or,  if  a  poor  man,  he  becomes 
an  out-patient  at  the  hospital.  Insomnia  may  supervene,  with 
symptoms  of  elation  or  depression,  or  else  the  establishment 
of  the  disease  may  be  definitely  ushered  in  by  a  cerebral  seizure. 
Physical  Signs.  Reflexes. — Amongst  the  earliest  of  these 
signs  is  loss  or  sluggishness  of  the  pupillary  reflex  to  light,  whilst 


( \  roup  of  general  paralytics. 


accommodation  is  unaffected  (the  Argyll-Robertson  pupil). 
The  sympathetic  and  consensual  reflexes  are  also  impaired.  The 
pupils  are  more  often  contracted  than  dilated  in  the  early  stages, 
andfrequently  they  are  unequal  in  the  two  eyes  (Fig  33).  The 
knee-jerks  are  usually  increased,  except  in  those  cases  associated 
with  Tabes,  in  which  they  are  absent.  The  skin  reflexes  for 
the  most  part  are  normal,  but  they  are  deficient  in  depressed 
cases.  An  important  reflex,  the  pharyngeal,  disappears  early 
in  General  Paralysis — stimulating  the  back  of  the  throat  with 
a  feather  frequently  produces  no  discomfort,  whereas  there 
is  no  marked  ansesthesia  in  the  skin. 


GENERAL   PARALYSIS  175 

Tremors. — Fibrillary  tremors  are  observed  in  the  protruded 
tongue,  in  the  lips  and  the  lower  part  of  the  face,  and  they  are 
increased  by  emotion.  Tremors  of  the  hands  are  also  notice- 
able, and  later,  the  manual  and  other  actions  are  quite  inco- 
ordinate. 

Gait. — At  first  active  and  brisk,  as  the  disease  progresses 
the  muscular  weakness  and  inco -ordination  result  in  a  shuffling 
gait,  and  finally  the  patient  is  bed-ridden,  with  muscular  wasting 
and  contractures. 

Congestive  Seizures. — These  occur  sooner  or  later  in  the 
vast  majority  of  cases,  and  are  accompanied  by  a  rise  in 
temperature.  They  are  generally  of  an  epileptiform  nature. 
Consciousness  is  usually  completely  lost,  but  in  the  slighter 


Fig.  33. — Uneqiial  pupils  in  general  paralysis. 

cases  with  local  "  sensations  "  or  a  "  faint,"  the  patient  is  aware 
of  his  condition.  The  "  fits  "  are  most  frequent  on  the  right 
side,  and  speech  for  the  time  being  is  implicated ;  but  in  some 
cases  both  sides  are  affected,  thus  resembling  genuine  Epilepsy, 
or  else  the  patient  may  have  "twitchings  "  only,  of  the  face, 
hand,  or  leg.  A  succession  of  fits  (Status  Epilepticus)  some- 
times terminates  fatally,  or  Apoplexy  from  ruptured  vessels 
may  be  the  determining  cause  of  death.  Previous  to  the  advent 
of  a  seizure,  the  patient  has  seemed  to  improve  in  his  general 
health,  although  becoming  gross  and  fat,  and  losing  his  facial 
expression.  After  each  seizure  the  patient  shows  marked 
deterioration,  both  mentally  and  physically,  but  he  invariably 
improves  again,  only  to  be  assailed  by  another  seizure,  until 
he  becomes  bedridden,  with  profound  Dementia,  and  he  finally 
dies  of  exhaustion. 

Visceral  Disorders. — The  digestive  functions  are  impaired 


176  MENTAL   DISEASES 

in  the  depressed  cases,  and  constipation  is  frequently  obstinate. 
The  heart's  action  becomes  gradually  weaker.  Pulmonary 
congestion  is  usual  towards  the  end.  The  bladder  often  gives 
considerable  trouble,  especiall}^  in  the  Tabetic  cases.  Retention, 
with  or  Avithout  overflow,  and  incontinence,  are  both  frequently 
met  with.  The  sexual  functions  are  in  abe3^ance  except  in  the 
early  stages  of  the  disease,  when  desire  is  often  much  increased, 
and  the  patient  sometimes  commits  himself  immorally. 

General  Nutrition. — At  the  onset  of  the  disease  there  is 
always  considerable  loss  of  weight.  This  may  continue  in 
the  depressed  forms  of  the  disease,  but  in  the  expansive  and 
demented  varieties  the  patients  tend  to  become  corpulent, 
mitil  reduced  by  seizures  to  the  terminal  stage.  The  skin 
becomes  greasy,  especially  about  the  face,  hands,  and  feet. 
The  blood  is  frequently  anaemic  with  some  leucocytosis.  The 
urine  may  be  increased  in  quantity.  The  cerebro-spinal  fluid 
contains  an  excess  of  globulin,  and  exhibits  an  abundant 
lymphoc3i:osis,  and  in  almost  all  cases  a  positive  Wassermann 
reaction  is  present  in  the  blood  and  in  the  cerebro-spinal  fluid. 

Trophic  Affections. — The  bones  become  fragile,  so  that 
fractures  may  arise  from  slight  injuries.  Occasionall}:^  an 
"insane  ear"  may  develop.  The  fmger-nails  may  become 
grooved.  Herpetic  eruptions  are  sometimes  seen.  Bed-sores 
are  prone  to  develop,  in  the  last  stage,  over  the  sacrum  and 
trochanter  and  on  the  heels,  especially  if  the  nursing  be  defec- 
tive. They,  however,  frequently  improve  and  cicatrise  under 
appropriate  treatment. 

Mental  Symptoms. — There  is  a  gradual  blunting  of  all 
the  special  senses,  but  perception  is  sometimes  acute  in  the 
early  stages  of  the  expansive  cases.  Hallucinations  are  not 
common,  but  are  prone  to  occur  as  regard  the  visual  and 
auditory  senses  in  about  25  %  of  cases.  Orientation,  as 
to  place  and  time  is  normal  at  first,  but  becomes  lost  as 
dementia  progresses.  Memory  is  impaired  from  the  beginning 
and  obeys  the  usual  mode  of  retrogression ;  proper  names  and 
recent  events  are  forgotten  first,  and  later  there  is  only  a 
distorted  recollection  of  the  past  or  else  the  memory  is  quite 
destroyed.  Attention  becomes  weak.  The  association  of 
ideas  slackens  and  becomes  disorganised  as  the  neuronic 
degeneration  advances.     The  patient  loses  all  insight  into  his 


GENERAL   PARALYSIS  177 

condition.  His  Judgment  is  so  impaired  that  delusions  of 
the  most  flagrant  character  arise.  Litellectual  operations  of 
an  abstract  nature  are  at  a  standstill.  Joffroy  has  pointed 
out  that  the  arithmetical  faculty  is  often  disordered  quite 
early  in  the  disease,  the  patient  being  unable  to  add  up  or 
multiply  simple  sums.  Li  expansive  cases,  patients  boast 
of  their  superhuman  strength  and  of  their  untold  wealth. 
The  exalted  cases  imagine  themselves  to  be  Kings,  Princes, 
]Milhonaires,  or  even  the  Deity.  Such  delusions  entail  endless 
trouble  in  the  early  stages,  before  the  patient  is  placed  under 
care.  The  patient  spends  all  his  money  on  useless  articles 
and  brings  ruin  on  his  family,  or  he  may  accidentally  commit 
suicide  in  some  absurd  attempt  to  fly  without  an  aeroplane, 
or  to  swim  across  the  Atlantic.  The  delusions  in  a  depressed 
case  are  of  an  exaggerated  character  also.  They  may  affect 
his  external  circumstances  or  himself ;  he  imagines  he  is  perse- 
cuted and  followed  by  detectives,  or  he  accuses  himself  of  being  a 
curse  to  the  whole  world,  or  he  has  hjqjochondriacal  delusions 
about  his  bodily  health,  and  fancies  that  he  is  blocked  up  for 
ever.  There  is  an  element  of  grotesqueness  and  exaggeration 
in  the  delusions  of  General  Paralysis  which  is  unusual  in  other 
cases  of  insanity.  Sometimes  the  delusions  are  of  an  altruistic 
character  and  the  patient  wishes  to  expend  his  imaginary 
miUions  for  the  benefit  of  the  poor.  Besides  his  voluntary 
actions  being  so  profoundly  disordered,  his  instincts  are  also 
mthout  proper  control.  He  hoards  up  rubbish,  and  runs  to 
excesses.  He  eats  like  a  glutton  and  bolts  his  food,  or  else  he 
refuses  food  altogether.  He  becomes  careless  in  his  attire, 
and  is  frequently  destructive  in  his  habits.  At  first  he  is 
unduly  emotional,  but  his  tears  or  laughter  are  shallow  and 
are  soon  over ;  and  as  the  degeneration  proceeds,  the  emo- 
tional life  dies  out,  and  the  face  is  expressionless.  The  speech 
and  handwriting  are  always,  sooner  or  later,  affected.  The 
speech  becomes  at  first  slow  and  hesitating.  The  patient 
is  unable  to  find  the  word  he  wishes  owing  to  lapse  of 
memory,  and  when  the  word  reaches  the  threshold  ot  con- 
sciousness, he  has  difficulty  in  its  articulation.  The  mouth 
and  tongue  quiver  with  increased  emotion.  Thickness  of 
speech  is  pronounced  in  advanced  cases  ;  words  such  as  Bibhcal 
Commentary,  Royal  Artillery,  are  difficult  to  utter.     Li  early 


178  MENTAL   DISEASES 

cases,  clipping  or  slurring  of  words  is  common.  In  the  last 
stage  there  is  often  entire  absence  of  ideas,  and  also  inability 
to  co-ordinate  any  movements,  In  the  manuscripts  of 
General  Paralj^tics — and  they  are  usually  prolific  writers — 
letters  and  words  are,  omitted,  and  repetitions  occur.  The 
calligraphy  changes  in  character,  and  becomes  larger  and  untidy. 
Li  the  early  stages  of  the  disease  the  patient  is  very  restless 
during  the  day  and  is  full  of  wants  which  cannot  be  granted. 
He  is,  as  a  rule,  a  good  sleeper  at  night,  and  frequently  takes  a 
nap  in  the  daytime  also.  The  General  Paralytic,  with  all  his 
brag  and  self-assertiveness,  is  really  easily  managed  when  placed 
under  care.  He  is  very  suggestible,  with  his  weakened  will 
power,  and  is  amenable  to  discipline.  He  is  also  easily  duped 
by  the  delusions  or  dishonesty  of  others. 

Stages. — Three  stages  are  usually  described  in  this  affec- 
tion. 

First  Stage. — From  the  established  onset  of  the  disease  to 
the  first  seizure.  The  paralytic  signs  are  few,  and  are  generally 
in  connexion  with  speech  and  the  reaction  of  the  pupils.  The 
patient  is  restless,  loses  flesh  and  looks  ill.  He  is  boastful 
or  else  weak-minded  and  emotional,  and  frequently  has  delu- 
sions.    The  memory  is  only  slightly  affected. 

Second  Stage. — The  patient  is  recovering  from  a  fit,  which 
leaves  him  worse  than  he  was  before.  His  memory  shows 
serious  lapses.  His  will  power  is  weak.  His  habits  and  instincts 
degenerate.  The  expression  of  his  face  alters,  he  loses  his 
higher  characteristics  and  grows  progressively  weaker.  He 
becomes  unhealthily  fat,  indeed  this  has  been  called  the  "fat, 
fatuous,  and  fitty  stage." 

Third  Stage. — The  paralysis  has  increased  so  that  he  has 
become  bedridden,  or  is  wheeled  about  in  invalid  chairs.  He 
is  now  quite  demented  and  takes  but  little  notice,  yet  he 
watches  for  his  food,  and  shows  some  pleasurable  sensation 
whilst  he  is  fed  by  his  nurse.  He  is  wet  and  dirty  in  his 
habits,  and  has  to  be  carefully  tended  to  prevent  bed-sores. 
Seizures  may  continue  in  this  stage,  or  the  end  may  be  gradual, 
by  progressive  fatty  degeneration  of  the  heart  and  of  other  vital 
organs.  Contractures  are  common,  grinding  of  teeth,  and  in- 
stinctive or  automatic  movements  only  remain.  Swallowing 
towards  the  end  is  difficult,  and  the  tube  is  frequently  resorted  to. 


GENERAL   PARALYSIS 


179 


Varieties  of  General  Paralysis.  Expansive  or 
Classical. — This  variety  is  less  common  than  it  used  to  be. 
The  patient  feels  well  and  frequently  says  he  was  never  better 
in  his  life,  although  there  are  indications  of  tremors,  and  other 
physical  signs  of  the  disease.  Delusions  of  exaltation  develop 
regarding  his  position  in  the  world,  and  he  frequently  alludes 
to  his  imaginarj^  muscular  strength.  He  talks  of  his  millions, 
or  wishes  to  distribute  his  money  wholesale. 

The  Maniacal  or  Excited. — This  is  sometimes  mistaken  for 


Fig.  34. — The  third  stage  of  general  paralysis. 

an  ordinary  case  of  Acute  Mania,  especially  when  the  physica 
signs  are  ill-defined.     The  patient  is  violent,  noisy,  and  de- 
structive.    The  excitement  after  a  time  abates,  and  frequently 
a  remission  in  the  progress  of  the  disease  takes  place. 

The  Melancholic  or  Depressed. — This  variety  resembles  an 
attack  of  Melancholia,  and  although  remissions  occasionally 
occur,  they  are  not  common — the  patient  often  drifting  into 
the  demented  class.  Delusions  may  arise  with  regard  to  the 
state  of  his  soul,  or  as  to  his  possessions,  and  he  asserts  he  has 
ruined  not  only  his  family,  but  the  whole  world.  Sometimes 
the  delusions  are  of  a  persecutory  nature,  but  they  do  not 
become  systematised  as  in  Paranoia. 


180  MENTAL   DISEASES 

The  Demeyited. — This  occurs  sometimes  without  any  seizures, 
the  patient  progressively  becoming  mentally  deteriorated  and 
physically  weaker,  without  much  excitement  or  depression,  and 
with  but  little  mental  activity  of  any  kind.  In  this  variety  the 
dementia,  which  sooner  or  later  supervenes  in  every  case,  is  a 
prominent  feature  from  the  beginning,  and  the  loss  of  memory 
is  marked. 

The  Spinal  or  Tabetic. — In  this  variety  the  spinal  cord, 
which  is,  usually,  ultimately  involved  in  most  cases,  is  affected 
early  and  the  symptoms  are  combined  with  those  of  Locomotor 
Ataxy.     Vesical  trouble  is  common. 

The  Juvenile  or  Adolescent. — This  is  a  rare  affection  occurring 
about  the  age  of  twenty,  and  is  always  associated  with  Con- 
genital Syphilis. 

Some  writers  describe  also  Acute  (or  Fulminating)  and  Con- 
vulsive Varieties,  in  both  of  which  the  patient  succumbs  in  a 
few  weeks  or  months.  Some  cases  of  General  Paralysis  also 
run  an  Alternating  course ;  thus,  there  may  be  excitement, 
depression,  or  stupor  of  a  more  or  less  periodic  form. 

The  disease,  as  it  affects  women,  is  usually  more  prolonged 
and  is  more  often  of  the  demented  variety. 

Diagnosis. — ^Of  the  utmost  importance  is  it  to  distinguish 
General  Paralysis  from  other  mental  disorders.  Hyslop,  in 
particular,  has  drawn  attention  to  the  various  conditions  that 
used  to  be  called  Pseudo-General  Paralysis  and  which  resemble 
the  disease.  It  is  unwise  to  give  a  decided  opinion  from  mental 
symptoms  only,  and  the  rule  is  to  wait  for  the  earliest  physical 
signs  to  appear,  such  as  tremors,  pupillary  defects,  difficulty 
in  articulation,  loss  of  reflexes,  seizures,  etc.  The  examination 
of  the  cerebro -spinal  fluid  by  lumbar  puncture  is  helpful  in  early 
cases,  lymphocytosis  being  almost  always  present.  The  disease 
must  ever  be  borne  in  mind  in  any  mental  disorder  in  a  man 
about  the  age  of  forty.  It  is  perhaps  most  often  confused  with 
Alcoholic  insanity,  especially  when  there  are  signs  of  organic 
disorder.  The  history  will  be  helpful  in  some  cases,  but  it 
must  be  remembered  that  General  Paralytics  have  sometimes 
been  heavy  drinkers.  Tremors,  defects  of  speech,  and  seizures 
occur  in  both,  but  more  in  General  Paralysis.  Visual  and  aural 
hallucinations,  as  well  as  anaesthesia  and  other  sensory  disturb- 
ances, are  less  common  in  General  Paralysis  than  in  Alcoholic 


GENERAL   PARALYSIS  181 

insanity.  The  Argyll-Robertson  pupil  rarely  exists  in  Alco- 
holic cases.  The  pupils  may  be  either  normal  or  irregular: 
but  they  usually  react  to  light,  although  sluggishly.  The  patient 
suffering  from  Alcoholic  insanity  also  does  not  sleep  so  well, 
and  at  times  he  has  terrifying  dreams ;  his  memor}'  is 
dulled  or  lost,  and  sometimes  perverted.  Cases  of  Maniacal- 
Depressive  and  Confusional  insanity'  are  closely  resembled  by 
some  acutely  excited  or  depressed  General  Paralytics.  The 
memory  defect  and  mental  deterioration,  however,  are  usually 
more  marked  in  the  latter ;  but  an  exact  diagnosis  maj"  not 
be  possible  till  the  somatic  signs  become  manifest.  Syphilitic 
insanit}',  and  insanity  from  Gross  Brain  Disease  (Organic 
Dementia)  have  usually  more  localising  signs,  and  optic 
neuritis  is  frequently  present.  Both  conditions  are  also 
comparatively  rare,  as  is  also  mental  disorder  associated 
"with  Lead  paralysis.  There  should  be  no  difficult}'  in  distin- 
guishing General  Paralysis  from  Paranoia,  Epilepsy,  and  other 
affections. 

Prognosis. — Li  the  majority  of  cases,  the  disease  runs  its 
course  to  a  fatal  termination  within  three  years .  Some  patients, 
however, improve  marvellously  and  appear  to  get  well,  the  disease 
being  arrested  for  a  period  of  months  or  even  a  few  years .  Al- 
though from  the  nature  of  the  remissions,  it  would  seem  feasible 
that  recovery  should  be  possible,  it  is  doubtful  whether,  so  far, 
this  has  ever  occurred,  in  spite  of  reports  to  the  contrary,  Th(> 
most  favourable  cases  for  remission  are  the  Excited  or  Maniacal 
ones.  The  Demented  cases,  especialh'  amongst  females,  some- 
times last  ten  or  more  years,  and  Tabetic  General  Paralytics 
usually  last  longer  than  the  average.  Complications  sometimes 
occur,  cutting  short  the  disease,  such  as  a  severe  Seizure,  Status 
Epilepticus,  Broncho-pneumonia  from  faulty  feeding  and  other 
causes.  Cystitis,  Urethral  fever  from  septic  catheterism,  or 
Septicaemia,  the  result  of  bed-sores.  Death  also  occasionally 
results  from  choking  and  other  accidents,  or  from  suicide. 

Pathology  and  Morbid  Anatomy. — ISTo  one  can  possibl}^ 
doubt  the  toxic  nature  of  the  disease,  and  the  fact  that  the 
poison,  wherever  generated,  enters  the  circulation  and  pervades 
the  whole  body.  The  changes  described  have  been  by  one 
school  termed  degenerative,  by  another,  inflammatory,  and  it 
is  probable  that  both  processes  occur.     It  is  indeed  difficult 


182  MENTAL  DISEASES 

to  say  whether  the  cortical  neurons  are  primaril}'  affected,  or 
whether  the  vascular  and  neuroghal  changes  take  place  first. 
Authorities  are  still  divided  on  these  points,  but  Mott  has 
done  much  to  support  the  theory  that  the  neurons  are  primarily 
involved,  and  that  the  disease  is  due  to  Syphilis.  It  has 
recentl}^  been  demonstrated  by  Noguchi  that  the  syphilitic 
organism  itself  has  been  fomid  in  the  brain  tissue  of  General 
Paralysis,  also  that  rabbits  are  rendered  syphilitic  by  the 
inoculation  of  cultures  from  the  cerebral  tissue  of  General 
Paralytics,  the  spirochetes  being  subsequently  found  in  the  tis- 
sues of  these  animals.  The  discussion,  indeed,  at  the  recent 
International  Medical  Congress  seemed  to  point  to  the  view  that 
Para-Syphilis,  after  all,  may  be  essentially  parenchymatous 
Syphilis.  Although  in  time  the  whole  of  the  cortex  becomes 
involved, the  most  marked  changes  occur  in  theRolandic  regions. 
Histologicalh',  the  destruction  of  the  pyramidal  cells  is  sho-v^m 
in  their  want  of  outline,  and  indistinctness  of  the  nuclei  which 
in  time  disappear,  and  by  the  presence  of  chromatolj^sis,  the 
Mssl  granules  disappearing  completely  and  the  cells  atrophjdng. 
The  dendrons  are  destro^'ed  as  the  disease  advances,  whilst 
the  degeneration  is  seen  equally  in  the  axis  cjdinder  processes. 
These  changes  also  occur  markedly  in  the  Frontal  Association 
areas.  Evidence  is,  moreover,  not  wanting  of  the  affection  of 
the  cranial  nerves,  the  mid-brain,  and  the  spinal  cord.  As 
regards  the  vascular  system,  the  vessels  are  tortuous,  distended 
mth  blood,  and  their  walls  are  thickened.  New  formation 
of  capillaries  occurs,  and  the  perivascular  canals  become 
choked  mth  cells  {vide  Fig.  48).  The  neuroglia  becomes  pro- 
liferated, and  there  is  an  abundance  of  spider  cells,  plasma  cells, 
rod  cells,  and  mast  cells,  whatever  their  significance  may 
mean. 

On  opening  the  skull,  which  is  sometim.es  heavier  than  nor- 
mal, the  dura  mater  is  thickened  and  adherent  in  parts,  as  is  also 
the  pia  arachnoid.  Sometimes  a  membrane  from  disorganised 
blood-clot  exists  between  the  dura  and  arachnoid.  On  attempt- 
ing to  strip  the  pia  from  the  cortex  a  worm-eaten  appearance 
is  often  left  (vide  Frontispiece,  Fig.  1).  There  is  wasting  of  the 
convolutions,  especially  of  the  grey  matter,  which  is  thinner  than 
normal ,  and  the  sulci  are  ver}'  apparent .  The  white  matter  is  soft 
and  shiny,  and  the  lateral  ventricles  are  dilated  with  an  excess  of 
cerebro -spinal  fluid.     This  excess  of  fluid  is  due  to  the  brain 


GENERAL   PARALYSIS  183 

shrinkage.  The  lining  of  the  ventricles  presents  a  frosted 
appearance.  This  is  specially  marked  on  the  floor  of  the  fourth 
ventricle  {vide  Fig.  44).  Sometimes  foci  of  haemorrhage  or  of 
softening  are  present.  Cholin  is  present  in  the  cerebro -spinal 
fluid,  with  an  excess  of  globulin,  and  an  abundant  lymphocytosis 
{vide  Fig.  45),  but  so  far,  no  specific  toxin  has  been  found  in  the 
fluid. 

The  blood-vessels  throughout  the  body  are  frequently  in 
a  state  of  endarteritis.  The  muscular  system  becomes  wasted 
and  shows  fatty  degeneration,  as  does  also  the  heart  muscle. 
The  lungs  are  oedematous,  and  there  is  often  evidence  of  Broncho- 
pneumonia. The  liver  and  kidneys  are  generally  affected.  The 
osseous  system  of  the  body  becomes  rarefied,  so  that  fractures, 
especially  of  the  ribs,  may  occur. 

Treatment. — Except  in  the  quiet  and  demented  cases,  it  is 
generally  necessary  for  a  patient  to  be  certified,  and  sent  to  an 
institution.  The  excitement  and  delusions  are  such  that 
adequate  control  cannot  be  otherwise  obtained.  The  patient, 
before  medical  advice  is  sought,  has  frequently  compromised 
himself  with  transactions  that  he  is  unable  to  carry  out.  The 
treatment  in  this  disease,  which  must  from  the  outset  stiU  be  re- 
garded as  hopeless  as  to  ^permanent  recovery,  can  be  palliative 
only.  The  patient  requires  the  tactful  management  of  trained 
nurses  or  companions.  Rest  and  quietude  should  be  enjoined 
as  much  as  possible,  but  the  lighter  recreations  and  amuse- 
ments are  quite  permissible.  The  patient,  when  curtailed  of  his 
extravagances,  is  usually  full  of  wants,  but  he  becomes  pecuHarly 
facile,  and  is  easily  convinced  by  ordinary  excuses,  without  much 
resentment  being  aroused ;  and  he  improves  under  discipline. 

During  any  phase  of  excitement,  alcohol  must  be  absolutely 
forbidden,  and  the  patient  should  be  encouraged  to  drink  milk 
as  a  beverage.  It  is  necessary  to  supervise  the  diet  of  General 
Paralytics,  for  reasons  previously  mentioned.  It  is  advisable 
to  have  their  food  cut  up  for  them,  as  the  disease  advances. 
In  the  last  stage  they  do  best  with  mince  and  slop  diet,  and 
they  have  to  be  fed  with  a  spoon  or  feeding  cup. 

After  a  seizure  it  is  sometimes  necessary  to  feed  with  a  tube 
for  a  few  times.  For  the  excitement,  a  mixture  of  Potassium 
Bromide,  gr.  xxx,  given  every  four  hours  has  sometimes  a  suffi- 
ciently calming  effect,  or  Sulphonal,  gr.  xx,  may  be  given  in 
the  late  afternoon. 


184  MENTAL   DISEASES 

Hypnotics  are  rarely  needed,  and  when  a  sleeping  draught 
is  required,  a  dose  of  Paraldehyde,  3j  ^o  3ij>  will  give  repose. 
Ordinary  symptoms  must  be  treated  on  general  lines,  and  the 
state  of  the  bowels  should  be  carefully  regulated.  The  patient 
seldom  has  any  insight  into  his  condition,  and  although  his 
state  is  pitiable  for  his  relatives  to  witness,  he  is  but  rarely 
capable  of  feeling  much  suffering.  The  condition  of  the  bladder 
requires  careful  attention,  and  some  cases  need  regular  cathe- 
terisation.  Air  cushions  and  a  water  bed  are  helpful  in  the 
bed-ridden  state,  and  the  healthy  nutrition  of  the  skin  must  be 
maintained  by  frequent  changes  of  position,  so  that  pressure 
may  be  evenly  distributed.  The  prevention  and  danger  of 
bed-sores  must  be  ever  before  the  medical  attendant,  so  that 
absolute  cleanliness  and  good  nursing  are  necessary.  Anti- 
Syphilitic  remedies,  so  far  have  proved  of  no  avail.  Salvarsan, 
or  Mercury,  given  by  intramuscular  injection  or  in  the  usual 
forms,  has  not  the  slightest  effect  in  staying  the  progress  of  the 
disease,  and  indeed  generally  does  harm.  The  same  may  be  said 
of  Iodide  of  Potassium.  The  injection  of  the  anti-paralytic  serum 
of  Ford  Robertson  also  has  not  met  with  the  success  that  was 
hoped  for.  Drawing  off  cerebro-spinal  fluid  by  lumbar  puncture 
does  but  little  good,  and  trephining  the  skull  has  proved  in- 
effectual, but  it  is  possible  that  by  means  of  Salvarsan  or  some 
such  drug,  or  of  prepared  serum,  introduced  direct  into  the 
cerebro-spinal  fluid  or  brain,  beneficial  results  may  ultimately 
and  safely  be  obtained.  The  treatment,  at  present,  largely 
resolves  itself  into  the  management  of  the  patient,  having  due 
regard  to  his  symptoms.  Sometimes  there  is  an  adequate  warn- 
ing of  a  seizure,  such  as  general  irritability  and  a  slight  rise  of 
temperature.  It  is  then  best  to  clear  out  the  bowels  with  a  drop 
of  croton  oil,  and  to  administer  a  dose  of  sedative  such  as  Chloral 
and  Bromide  by  the  mouth,  or  per  rectum.  This  is  particularly 
necessary  during  Status  Epilepticus.  Urotropine,  gr.  v  to  x  is  a 
drug  which,  owing  to  its  sterilising  effect  on  the  cerebro-spinal 
fluid,  has  its  advocates  in  the  treatment  of  General  Paralysis. 
Intra-muscular  injections  of  Nucleinate  of  Sodium,  two 
grammes  to  100  c.cm.,  or  even  Tuberculin  is  also  credited 
with  producing  a  remission  of  symptoms. 

When  a  remission  occurs,  the  question  arises  as  to  what  is 
the  best  thing  to  do.     The  relatives  will  probablj^  consider 


GENERAL   PARALYSIS  185 

there  has  been  an  error  in  diagnosis,  or  they  believe  the  patient 
to  be  cured.  In  no  case  should  he  be  allowed  to  cohabit  if  he 
leaves  the  institution,  and  then  it  is  wisest  to  let  the  certificates 
remain  in  force.  The  majority  of  remissions  only  last  about 
three  months,  and  the  patient  relapses  into  his  former  state, 
often  preluded  by  a  seizure,  but  it  must  be  admitted  that 
occasionally  a  remission  exceeds  one  or  more  years.  Rarely 
does  the  disease  run  a  course  in  which  the  mental  symptoms 
are  negligible. 


CHAPTER   XV 

ALCOHOL    AND    INSANITY 

Some  close  connexion  between  drink  and  mental  disorder 
is  obvious  to  everyone.  Alcohol,  indeed,  heads  the  list  as  a 
causative  agent  in  the  production  of  the  so-called  toxic  in- 
sanities. It  is  to  be  noted  at  the  outset  that  the  kind  of 
mental  disturbance  attributed  to  alcohol  depends,  in  some 
measure,  on  the  amount  of  the  poison  imbibed,  and  on  the 
length  of  period  during  which  the  nervous  system  has  been 
subjected  to  its  influence.  Moreover,  the  essential  mental 
constitution  of  the  patient  does  much  to  colour  the  symptoms 
of  the  disorder  present.  In  the  opinion  of  Archdall  Reid  and 
others,  alcohol  is  looked  upon  as  an  important  factor  in  evolu- 
tion. They  consider  that  every  civilised  nation  passes  through 
a  drunken  phase,  and  only  those  particular  stocks  that  acquire 
an  immunity  survive.  Habit  and  experience  favour  the 
moderate  use  of  alcoholic  beverages  in  those  who  are  normal 
and  have  reached  maturity.  Although,  from  the  laboratory 
point  of  view,  the  output  of  work  may  be  better  in  the  total 
abstainer,  yet,  practically  and  socially  a  person  is  happier  and 
better  who  can  take  a  little  harmless  wine  with  his  meals. 
An  ordinary  individual  should  be  able  to  oxidise  two  ounces 
of  ethylic  alcohol  in  the  twenty-four  hours  with  impunity. 
The  insanity  that  occurs  from  alcoholism  is  seen  mostly 
in  those  who  have  been  addicted  to  spirit-drinking  over  a 
period  of  years.  It  is  probable  also  that  the  quality  of  the 
spirit  has  some  effect.  The  higher  alcohols  and  aldehydes  in 
many  brands  of  whisky,  brandy,  and  other  spirits  have  a  more 
pernicious  effect  than  has  ethylic  alcohol  alone.  The  same 
may  be  said  with  regard  to  malted  liquors,  although  they  less 
commonly  lead  to  any  form  of  chronic  insanity.  Every  normal 
individual  has  a  specific  resisting  power  to  the  pathological 

186 


ALCOHOL   AND   INSANITY  187 

influence  of  alcohol,  but  it  varies  somewhat  in  different  persons. 
Some  are  quite  intolerant  even  to  small  doses.  This  intol- 
erance occurs  in  neuropathic  families  and  especially  amongst 
the  epileptic  and  insane.  Susceptibility  to  its  harmful 
influence  may  also  be  acquired  from  injury  to  the  head  or 
sunstroke,  and  from  the  after-effects  of  some  zymotic  and 
other  diseases.  Alcoholism  is  frequently  seen  as  a  symptom 
rather  than  a  cause  of  mental  disease.  Thus  a  man  may 
drink  to  excess  in  the  excited  stage  of  Maniacal-Depressive 
insanity  or  to  drown  his  sorrow  in  the  depression  of  the  same 
disorder,  or  again  a  patient  may  become  alcoholic  during  the 
exaltation  and  loss  of  self-control  of  General  Paralysis. 
Dipsomania  is  a  disorder  with  an  intermittent  craving,  and 
although  described  in  this  Chapter,  is  more  akin  to  Impulsive 
insanity  (Psychasthenia). 

Etiology. — Alcoholism  is  decidedly  a  family  disease,  and 
the  tendency  to  drink  is  handed  down  from  parent  to  offspring  in 
many  cases.  Example  plays  an  important  part,  and  children 
are  often  taught  to  drink  from  early  years.  There  is  fre- 
quently a  history  of  mental  instability  or  neurosis  present. 
The  offspring  in  early  years  are  liable  to  convulsions  and 
nightmares,  and  are  often  degenerate.  Alcohol,  by  some,  is 
drunk  to  excess  in  imitation  of  others ;  for  instance,  convivial 
drinking  becomes  a  custom  for  social  purposes,  or  industrial 
drinking  to  promote  business.  Thus  a  pernicious  habit  is 
initiated  in  those  who  have  no  innate  predisposition.  In  this 
way  a  course  of  constant  "  nipping  "  is  frequently  brought 
about  which  spells  ruin  to  the  higher  nervous  system.  It  is 
incumbent  on  every  medical  man  to  be  wary  in  ordering 
stimulants  for  slight  ailments,  for  fear  of  starting  the  alcoholic 
habit.  This  applies  particularly  to  women  with  menstrual 
troubles,  and  especially  at  the  time  of  the  menopause. 

Varieties. — It  will  be  necessary  to  mention  :  (1)  Drunken- 
ness or  Inebriation ;  (2)  Delirium  Tremens;  (3)  Chronic  Alco- 
holism and  Alcoholic  Insanity ;  and  (4)  Dipsomania. 

1.  Drunkenness,  Inebriation,  or  Acute  Alcoholism, 
may  be  defined  as  the  effect  of  alcoholic  stimulants,  by  which  the 
senses  and  the  mental  or  bodily  functions  of  a  person  are  im- 
paired, so  that  he  becomes  incapacitated  according  to  the  degree 
of  intoxication.     The  condition  is  usually  due  to  a  large  amount 


188  MENTAL   DISEASES 

being  consumed  rapidly,  but  a  less  quantity  will  produce 
the  same  condition  in  predisposed  persons. 

Physical  Signs. — The  pulse  becomes  frequent  and  the 
arteries  are  dilated,  so  that  there  is  at  first  a  general  feeling 
of  warmth  and  hien-etre,  although  the  temperature  is  generally 
subnormal.  Articulation  is  blurred,  there  is  usually  some 
muscular  inco-ordination  which  is  exhibited  by  inability  to 
walk  straight,  or  to  turn  round  suddenly,  or  to  stand  still  with 
the  eyes  closed.  The  tongue  is  coated  and  sometimes  tre- 
mulous, and  the  patient  not  infrequently  vomits  later,  or  falls 
into  a  deep  sleep.  The  special  senses  are  blunted  or  disordered. 
The  conjunctivae  are  congested,  the  eyes  glassy,  the  pupils 
sometimes  fail  to  react  to  light,  and  are  perhaps  irregular, 
and  there  may  be  strabismus. 

Mental  Symptoms. — The  sense  of  fatigue  is  diminished. 
The  association  of  ideas  is  increased  and  disordered.  Memory 
and  the  reasoning  powers,  volition  and  self-control  are  impaired, 
so  that  the  patient  frequently  becomes  a  nuisance  or  gets  into 
trouble.  The  moral  sense  is  reduced  to  a  lower  level,  and  the 
patient  is  apt  to  be  boastful.  He  frequently  loses  the  sense 
of  time,  and  sometimes  that  of  place.  The  patient's  emotional 
state  varies  according  to  his  essential  mental  constitution. 
He  may  be  uproarious  or  jovial,  loquacious,  or  mute  from 
depression.  Many  are  quarrelsome  and  aggressive,  and  some 
are  even  dangerous.  Drink  is  indeed  a  potent  cause  of  crime 
as  well  as  of  minor  offences,  especially  in  the  lower  classes.  In 
persons  of  a  neuropathic  taint,  drink  may  cause  a  veritable 
state  of  iurj — Mania  a  Potii — the  patient  being  quite  beside 
himself,  so  that  he  may  be  homicidal  or  may  injure  himself,  or  he 
may  commit  an  indecent  assault  and  have  no  recollection  of 
it  on  recovery.  Some  patients  become  subject  to  a  transient 
but  deep  depression  with  suicidal  tendencies.  In  pronounced 
cases  of  alcoholic  intoxication  the  patient  lies  in  a  comatose 
state  which  may  terminate  fatally,  with  or  without  an  epilepti- 
form or  apoplectic  seizure.  In  ordinary  cases  recovery  takes 
place  in  a  few  hours,  but  this  may  be  delayed  in  severe  con- 
ditions for  a  few  days. 

Diagnosis. — Various  tests  are  applied,  which,  however,  are 
not  altogether  satisfactory,  and  the  history  and  the  smell  of 
alcohol  are  usually  most  reliable ;  but  it  must  be  remembered 


ALCOHOL   AND   INSANITY  189 

that  stimulants  may  have  been  taken  as  a  remedy  for  some 
other  affection,  so  that  a  careful  examination  should  be  made 
for  any  trace  of  organic  disease,  e.  g.  Uraemia,  Diabetes, 
Cardiac  or  Nervous  Disease,  or  Opium  poisoning,  etc. 

Treatment. — A  purge  suffices  in  ordinary  cases  and 
Caffeine  or  hot  coffee  should  be  administered.  To  remove  the 
poison,  if  the  patient  is  seen  early,  the  stomach  should  be  washed 
out  with  a  tube,  and  he  should  be  carefully  nursed  in  bed. 

2.  Delirium  Tremens. — This  disorder  is  most  apt  to  be 
developed  when  a  chronic  drunkard  has  met  with  some  in- 
jury, such  as  a  fracture,  or  has  become  subject  to  Pneumonia 
or  some  other  intercurrent  malady.  In  such  conditions,  it  is 
usual  to  withhold  stimulants  until  indication  for  their  use 
ensues,  and  when  Delirium  Tremens  supervenes,  the  sudden 
deprivation  from  alcohol  is  generally  held  to  be  a  contribu- 
tory cause.  There  is  something  to  be  said  for  this  view,  but 
as  a  matter  of  fact  the  deprivation  of  alcohol  in  a  drunkard 
who  has  not  been  subjected  to  any  injury  or  physical  disease, 
does  not  usually  cause  Delirium  Tremens.  Moreover,  as 
the  disorder  becomes  evident,  the  patient's  desire  for  alcohol 
declines,  and  he  may  even  have  an  aversion  for  it,  so  that  the 
abstention  from  alcohol  may  almost  be  regarded  as  an  early 
symptom  of  the  disorder.  It  would  appear  in  many  cases  as 
if  a  secondary  auto -intoxication  were  brought  about  by  the 
effect  on  the  nervous  system  of  a  sudden  injury,  or  the  ac- 
cession of  some  blood  poison,  which  produces  an  attack.  A 
patient  who  has  once  had  Delirium  Tremens  is  liable  to  have 
further  attacks,  if  he  persists  in  his  alcoholic  habits. 

Physical  Signs. — The  patient  is  flushed,  looks  ill  and 
is  invariably  bathed  in  perspiration.  He  is  restless  and  is 
always  fidgeting  about  with  his  fingers.  The  muscular  system 
is  weak,  tremors  are  present,  and  the  articulation  is  blurred. 
Sleeplessness  is  marked.  The  tongue  is  coated  and  tremulous  ; 
the  patient  is  liable  to  gastric  attacks,  and  he  generally  refuses 
food.  Constipation  is  common.  The  pulse  is  rapid  and  of 
low^  tension,  and  in  fatal  cases  (about  5  °o)  it  is  usually  the 
heart  that  gives  out.  Respiration  is  frequent.  The  tempera- 
ture varies  from  normal  to  100°  F.  The  urine  sometimes 
contains  albumen  from  co-existing  kidney  disease. 

Mental    Symptoms. — Before    the    disorder    has    quite 


190  MENTAL   DISEASES 

developed  the  patient  is  restless,  irritable  and  cannot  sleep.  The 
mental  symptoms  are  worse  at  night-time  and  consist  largely 
of  disturbances  of  perception ;  he  becomes  the  subject  of 
active  visual  hallucinations,  mostly  of  a  terrifying  nature. 
He  sees  "  blue  devils,,"  rats,  serpents,  etc.  crawling  about. 
He  also  feels  them,  and  is  under  the  influence  of  aural 
hallucinations,  he  hears  "  voices  "  of  people  who  say  they 
are  going  to  murder  him.  Sometimes  he  imagines  his 
food  is  poisoned,  and  he  complains  of  foul  odours.  The 
hallucinations  are  very  variable,  as  are  also  the  delusions 
which  are  associated  with  them.  He  is  timorous  and  de- 
pressed, as  a  rule,  although  in  a  minority  of  cases  exaltation 
occurs.  The  patient  becomes  disorientated.  He  mistakes 
the  identity  of  people  and  has  no  proper  sense  of  his  sur- 
roundings. The  memory  of  events  during  an  attack  is  very 
vague,  although  he  remembers  incidents  clearly  of  years  ago. 
He  is  impulsive  in  his  actions,  and  his  violence  may  lead  to 
suicidal  or  homicidal  attacks.  He  imagines  that  he  is  working 
at  his  usual  daily  occupation,  and  he  may  do  so  for  hours  in  a 
grotesque  manner — the  'bus-driver  using  perhaps  string  or  a 
bandage  tied  to  the  end  of  the  bed,  as  reins  for  imaginary 
horses.  His  attention  can  only  be  roused  by  speaking  firmly 
to  him  and  then  but  temporarily. 

Treatment. — A  darkened  bedroom  with  plenty  of  skilled 
nurses  is  requisite.  The  patient  must  be  protected  from  his 
impulsive  tendencies  and  the  windows  and  fireplace  should 
be  guarded.  He  is  technically  certifiable,  and  can  be  sent 
away  on  an  urgency  order  to  an  asylum,  or  if  a  pauper, 
to  the  workhouse  infirmary  as  a  halfway  house,  where  most 
of  these  cases  recover.  A  plentiful  supply  of  nourishment 
should  be  given,  such  as  milk  and  eggs  with  an  occasional  basin 
of  soup.     The  tube  may  be  necessary,  if  all  food  is  refused. 

As  the  patient  improves,  solid  diet  may  be  given,  and 
exercise  in  the  fresh  air  will  help  towards  convalescence. 
Calomel  and  saline  aperients  should  be  given  at  intervals. 
For  the  persistent  insomnia  and  restlessness  it  may  be  neces- 
sary to  administer  Sulphonal  gr.  xxx,  or  Trional  gr.  xx.  It 
is  useless  to  give  Chloral  and  Bromide  in  ordinary  doses,  but 
a  half-dram  of  the  former  at  night  with  a  dram  of  the  latter 
sometimes  produces  sleep.     Opium  is  also  occasionally  given 


ALCOHOL   AND   INSANITY  191 

with  satisfactory  results.  All  alcohol  should  be  rigidly  prohibited 
unless  the  patient  becomes  collapsed,  when  brandy  will  generally 
effect  a  restoration.  The  patient  should  be  kept  for  some  time 
under  supervision  after  recovery  takes  place,  to  prevent  relapse 
to  former  habits.  During  an  attack,  if  ample  means  are 
available  for  a  supply  of  trained  nurses,  a  patient  can  be 
managed  at  his  own  house  or  in  a  nursing  home. 

3.  Chronic  Alcoholism  and  Alcoholic  Insanity. 
Chronic  Alcoholism  when  once  established  too  often  continues 
for  the  rest  of  life.  It  causes  a  gradual  but  progressive  mental 
and  moral  degradation  of  the  patient,  which  is  sometimes  just 
short  of  certifiable  insanity.  It  produces  untold  misery  in  a 
household  and  the  drinker  becomes  a  disgrace  to  his  family. 
The  chronic  drunkard's  word  cannot  be  relied  on,  he  sinks  in 
the  social  scale.  He  is  muddled,  slovenly  in  attire,  unable  to 
do  anything  until  he  has  partaken  of  a  drink  to  steady  his 
nerves.  He  is  subject  to  dyspepsia  and  morning  sickness,  his 
hands  tremble  and  his  bodily  health  fails ;  and  unless  placed 
under  medical  treatment,  he  becomes  a  curse  to  his  relatives 
or  he  gets  into  the  hands  of  the  police,  or  drinks  himself  to 
death. 

In  Alcoholic  Insanity,  however,  the  symptoms  usually  come 
on  less  gradually.  There  is  a  decided  change  in  the  character 
of  the  individual,  or  his  conduct  has  recently  become  so  much 
affected  that  the  case  is  at  once  recognised  as  one  of  mental 
disease.  Most  cases  exhibit  a  state  of  confusion  with  hallu- 
cinations, which  has  been  already  described  as  (1)  Acute  Con- 
fusional  insanity  {vide}).  125),. the  less  acute  cases  being  called 
Hallucinatory  insanity ;  others  are  markedly  suspicious  and 
delusional,  this  type  may  be  termed  (2)  Alcoholic  pseudo- 
Paranoia  ;  whilst  others  are  the  so-called  cases  of  (3)  Alcoholic 
"pseudo-General  Paralysis ;  the  termination  in  the  irrecoverable 
cases  being  (4)  Alcoholic  Dementia.  Some  cases,  mostly 
females,  are  associated  with  peripheral  neuritis,  producing  the 
disorder  known  as  (5)  Korssakow's  disease  or  the  Polyneuritic 
psychosis.  This  syndrome  is  also  occasionally  caused  by  other 
toxic  agents,  such  as  Arsenic,  Lead,  Diabetes,  Influenza,  etc. 

Physical  Signs. — The  patient  commonly  has  distended 
venules  over  the  face  and  nose,  and  the  hands  are  congested. 
There  is  tremor  of  the  tongue  and  lips,  and  twitchings  of  the 


192  MENTAL   DISEASES 

facial  and  other  muscles.  His  articulation  is  difficult.  The 
patellar  reflex  may  be  exaggerated,  or  it  may  be  absent  if 
there  is  neuritis  of  the  lower  extremities  (Korssakow).  This 
latter  is  often  accompanied  by  pains  in  the  calves,  and 
tingling  sensations  or.  anaesthesia.  Seizures  or  fits  are  some- 
times met  with,  the  convulsions  being  mostly  of  an  epileptiform 
nature,  so  that  some  cases  simulate  General  Paralysis.  The 
pupils  may  be  small  or  large  and  often  irregular,  and  they 
react  feebly  to  light.  The  patient  walks  with  ^n  awkward 
gait,  the  tremor,  inco-ordination,  or  paresis  showing  itself  also 
in  other  movements,  including  the  handwriting.  The  bladder 
and  rectum  frequency  require  attention  as  the  patient  becomes 
demented. 

Mental  Symptoms. — The  patient  is  confused,  and  shows 
general  mental  weakness  and  degradation.  His  memory  fails 
for  current  events  or  it  is  perverted,  and  he  is  apt  to  romance 
and  fabricate  stories  which  he  believes  to  be  true.  These 
pseudo-reminiscences  must  be  looked  upon  as  illusions  of  memory 
(paramnesia).  He  is  untidy  in  his  appearance,  careless  in  man- 
ners, and  loses  his  higher  acquirements.  He  has  general  dis- 
turbance of  perception,  with  hallucinations  or  illusions  of  the 
senses.  '  The  noises  in  the  ears  may  be  vague  at  first,  but  in  time 
they  are  interpreted  as  "voices  "that  taunt  or  persecute  the 
patient.  These  "  voices  "  are  worse  at  night,  when  he  keeps  up 
a  running  conversation  with  them.  Likewise  he  sees  strange 
"  visions  "  which  he  connects  with  the  "  voices  "  of  con- 
spirators. The  skin  sensations  are  disturbed,  so  that  many 
patients  complain  of  little  animals  crawling  about  them  and 
of  electrical  and  mesmeric  influences.  Similarly,  taste  and 
smell  are  affected,  and  he  is  consequently  suspicious  about  his 
diet.  Delusions  of  all  sorts  may  be  present  according  to  the 
emotional  state  of  the  patient.  Thus,  a  patient  may  be  exalted, 
believing  himself  a  King  or  even  the  Deity,  or  he  may  be 
depressed,  imagining  himself  the  victim  of  the  evil  machinations 
of  others.  Suspicion  is  also  an  ordinary  symptom  of  the 
disorder  and  is  associated  with  delusions  of  persecution.  Thus, 
a  husband  becomes  suspicious  of  his  wife's  conduct  and  is 
jealous  of  the  attentions  of  others,  and  he  accuses  her  of  un- 
faithfulness, or  vice  versa.  Delusions  and  hallucinations  are 
prone  to  lead  to  impulsive  actions,  and  the  patient  may  become 


ALCOHOL   AND   INSANITY  193 

violent  and  suicidal.  Automatic  dream-states  also  occur.  As 
the  disease  progresses,  the  memory  becomes  worse  and  worse, 
until  finally  the  patient  is  quite  demented,  and  is  defective 
in  all  his  habits.  He  is  inclined  to  be  wakeful  at  night. 
His  letters  and  manuscripts  also  indicate  the  condition  fully. 

Diagnosis. — -A  reliable  history  will  do  much  to  establish  a 
correct  diagnosis.  General  Paralysis  is  the  condition  which 
has  to  be  distinguished  from  it,  if  possible.  It  must  be 
remembered  4ihat  Alcoholism  is  sometimes  a  symptom  of 
General  Paralysis  and  other  insanities,  and  that  a  history 
of  Syphilis  does  not  necessarily  infer  the  supervention  of 
General  Paralysis.  Active  hallucinations,'^  sensory  disturb- 
ances, insomnia  at  night,  and  a  terrified  state  favour  the 
diagnosis  of  Alcoholic  insanity.  Tremors,  paralysis  and  con- 
vulsions occur  in  both.  The  Argyll-Robertson  pupil  points  to 
General  Paralysis  as  does  also  a  greasy  skin  and  a  hesitating 
slurring  speech.  Letters  are  left  out  in  words  that  the  patient 
writes  more  often  in  General  Paralysis  than  in  Alcoholic 
insanity.  Lumbar  puncture  may  be  resorted  to  for  the  purpose 
of  clearing  up  a  doubtful  case. 

Prognosis. — This,  in  a  recent  case,  is  as  a  rule  good  for  the 
immediate  attack,  from  which  the  patient  recovers  perhaps 
with  a  little  defect  of  memory,  but  he  is  apt  to  drink  again 
and  to  relapse  into  a  state  of  insanity.  It  is  surprising  to  see 
how  some  cases,  even  with  apparent  Dementia  and  organic 
paralysis,  improve  in  a  few  months,  so  that  the  practitioner 
should  be  careful  in  giving  a  bad  prognosis.  "  To  the  Alcoholic 
all  things  are  possible  "  (Savage).  Some  cases  die  from  con- 
vulsions or  heart-failure.  The  Pseudo -Paranoiac  cases  im- 
prove under  care,  but  always  relapse  when  they  return  home 
without  supervision. 

Pathology.— Alcohol  in  these  cases  seems  to  have  a  special 
affinity  for  the  nervous  system.  Rarely  is  the  liver  or  a 
kidney  found  to  be  cirrhotic  or  enlarged.  The  cortex  cerebri 
and  the  peripheral  nerves  are  affected  according  to  their 
individual  resisting  powers.  This  is  due  to  the  poison  of 
alcohol  itself,  but  also  to  a  process  of  auto-intoxication  from 
perverted  metabolism.  In  recent  cases  there  is  little  abnormal 
to  be  found  in  the  brain,  but  in  chronic  patients  the  changes 
usually  observed  in  Dementia  are  to  be  seen  in  the  nervous 
o 


194  MENTAL   DISEASES 

elements,  the  vessels,  and  the  neuroglia.  The  convolutions 
are  atrophied.  The  dura  mater  and  pia  are  thickened,  the 
arachnoid  showing  milky  patches.  The  ventricles  are  dilated. 
The  vessels  are  thickened,  the  coats  being  atheromatous  and 
fatty,  and  the  minute  arterioles  have  aneurysmal  swellings. 
The  perivascular  spaces  are  distended  with  cells.  The  neu- 
roglia is  increased  and  spider  cells  are  abundant.  The  nerve 
cells  are  disorganised  and  shrunken,  some  of  the  motor  cells 
being  completely  atrophied,  their  processes  having  disappeared. 
There  is  not,  however,  so  profound  or  general  a  degenerative 
change  as  is  the  case  in  General  Paralysis. 

Treatment. — No  good  will  be  done  in  a  pronounced  case 
of  Chronic  Alcoholism  or  Alcoholic  insanity  until  the  patient  is 
sent  from  home.     Sometimes  the  relations  are  most  anxious  to 
avoid  an  asylum  or  an  inebriate  home,  and  in  such  a  case,  a 
suite  of  rooms  may  be  set  apart  and  a  staff  of  nurses  engaged 
to  treat  the  patient.     This  is  not  satisfactory  unless   means 
are  ample,  and  there  is  a  garden  for  exercise.     Care  should  be 
taken  that  the  nurses  are  absolutely  trustworthy,  that  they 
do  not  accept  bribes,  and  that  the  orders  from  the  visiting 
medical    attendant    are   carried    out.     The   alcohol   must   be 
withdrawn,  and  it  is  usually  best  to  carry  this  out  forthwith. 
The  patient  will  be  worse  for  a  few  days,  retching  and  vomiting, 
and  will  be  more  tremulous.     The  bowels  must  be  attended  to, 
and  the  bladder  evacuated.     The  pulse  should  be  carefully 
watched,  and  if  the  patient  shows  signs  of  collapse,  a  little 
alcohol  may  be  given  at  night-time  for  a  few  days.      The 
patient  should  be  fed  up  as  much  as  possible — milk,  custards 
and  soups  are  all  that  he  will  probably  take.     Refusal  of  food 
may  require  tube  feeding.     For  the  sleeplessness,  a  dose  of 
Chloral  and  Bromide  may  be  given,  or  at  the  onset  when  severe 
depression  is  present,  a  dose  of  alcohol  in  milk  may  be  given. 
Quinine  and  Iron  should  be  administered  during  convalescence, 
and  the  patient  be  allowed  out  in  the  fresh  air  under  close 
supervision.      The  treatment   of  Acute   Confusional  insanity 
has  already  been  dealt  with  {vide  p.  129),  and  for  the  manage- 
ment of  other  Alcoholic  conditions,  reference  may  be  made  to 
the  Chapter  on  General  Treatment. 

4.  Dipsomania. — This  is  a  variety  of  Impulsive  Insanity 
(Psychasthenia)  in  which  the  impulse  or  craving  to  drink  in 


ALCOHOL  AND   INSANITY  195 

excess  occurs  in  cycles,  closely  resembling  those  in  Periodic 
insanity.  The  condition  is  therefore  quite  different  from 
Drunkenness,  which  is  caused  by  alcohol;  in  Dipsomania  the 
craving  for  drink  is  symptomatic  of  the  disorder,  and  some- 
times in  the  intervals  between  the  attacks  the  patient  has  a 
distinct  aversion  for  alcohol.  The  patient  may  strive  to 
overcome  his  paroxysmal  weakness,  but  is  impelled  thereto 
by  a  depressing  influence  that  his  weakened  will-power  is 
unable  to  resist.  He  becomes  fretful  and  irritable,  unable  to 
take  his  food  or  to  sleep  naturally.  He  often  seeks  protection 
between  the  attacks,  or  at  the  first  sign  of  an  impending  bout. 
When  once  the  patient  tastes  alcohol,  he  drinks  to  excess  until 
the  bout  is  over,  during  which  also  he  may  develop  Delirium 
Tremens,  as  a  complication. 

Treatment. — This  can  sometimes  be  managed  in  private 
care,  but  is  best  carried  out  in  an  asylum  or  in  an  inebriates' 
retreat;  the  procedure  for  admission  into  the  latter  is  men- 
tioned on  p.  278.  Alcohol  should  be  cut  off  promptly,  as  a  rule, 
but  gradually  in  a  few  cases  in  which  the  general  health  is  seri- 
ously impaired.  The  patient  needs  abundant  nourishment 
and  good  nursing.  A  bitter  tonic  such  as  Quinine  should  be 
given  as  the  patient's  health  is  restored.  A  certain  class  of 
patient  is  benefited  by  Hypnotism ;  the  suggestions  being 
continued  over  a  prolonged  time  to  prevent  relapse.  Many 
so-called  "  drink  cures  "  are  composed  of  innocuous  agents 
and  their  influence  is  due  to  Suggestion. 


MORPHINISM 

Morphinism  in  certain  neuropathic  individuals  may  be 
contracted  after  one  or  two  injections.  Ordinary  people, 
however,  must  have  been  subject  to  its  influence  for  some 
weeks  before  a  craving  becomes  established.  It  behoves 
medical  men  to  be  cautious  in  ordering  this  sedative  and  no 
patient  should  be  entrusted  with  a  syringe  for  self -use.  Most 
cases  occur  amongst  doctors  and  nurses,  of  a  neurotic  type. 
It  is  probable  that  the  expense  of  the  drug  fortunately  checks 
its  abuse  amongst  the  lower  classes.  The  habit  is  mostly 
derived  from  the  continual  use  of  the  hypodermic  syringe. 


196  MENTAL   DISEASES 

but  it  may  result  also  from  the  abuse  of  suppositories,  pills, 
and  medicines  containing  Morphia  or  Opium,  and  from  smoking 
or  eating  Opium.  A  patient  is  given  the  narcotic  to  produce 
sleep  or  to  allay  facial  neuralgia,  sciatica,  etc.,  and  its  ad- 
ministration is  repeated.  He  seems  to  require  increasingly 
larger  doses  to  produce  the  same  effect,  whilst  the  after-results 
of  depression  and  lassitude  induce  in  him  a  desire  for  the 
drug  a  few  hours  after  its  pleasurable  action  has  worn  off. 
It  produces  a  quiescent  and  happy  feeling  and  increases  the 
power  of  imagination,  so  that  work,  both  mental  and  physical, 
is  apparently  more  easily  executed.  A  patient  comes  for 
advice,  or  is  brought  by  his  relatives  for  treatment,  because 
his  physical  health  becomes  affected  by  the  large  doses  that 
are  requisite  for  him  to  enable  him  to  carry  out  his  work 
at  all.  He  is  dyspeptic  and  constipated,  disinclined  for 
food  and  becomes  frightened  as  to  what  is  going  to  happen. 
He  finds  he  does  not  perform  his  duties  as  well  as  he  did,  and 
that  his  moral  nature  is  deteriorating.  Although  some  persons 
can  take  Morphia  or  Opium  for  years  without  pronounced 
mental  symptoms,  the  majority  become  chronically  confused, 
indolent  and  incapacitated.  The  memory  fails  and  the 
emotional  state  varies  from  excitement  to  depression.  There 
may  be  sensory  effects,  but  these  are  more  usual  if  the  patient 
is  also  addicted  to  Alcohol  or  Cocaine.  Patients  become  un- 
truthful and  are  liable  to  make  false  accusations  against 
others.  The  general  health  is  disturbed,  the  secretions 
being  dried  up  except  the  sweat,  which  is  increased.  The 
appetite  is  bad  and  constipation  is  frequent,  the  pupils  are 
small,  the  blood  is  anaemic  and  the  pulse  is  poor.  The 
sexual  functions  are  in  abeyance.  The  symptoms  of  sudden 
abstinence  from  the  drug  in  the  case  of  an  habitue  are  those 
of  intoxication  by  an  auto-antidote.  Vomiting  and  diarrhoea 
set  in  and  tenesmus  is  common.  The  cardiac  action  is  weak 
and  the  patient  may  become  collapsed.  His  special  senses 
are  all  hypersesthetic.  He  feels  cold  and  has  to  have  extra 
blankets  on  his  bed.  He  is  troubled  also  with  strong  sexual 
desire  and  painful  erections.  He  complains  of  neuralgic  pains 
and  muscular  cramps.  He  becomes  the  victim  of  absolute 
insomnia,  and  is  deeply  depressed  and  miserable,  pacing  about 
restlessly,  and  asking  to  be  relieved  by  a  last  injection.     The 


MORPHINISM  197 

severity  of  the  abstinence  symptoms  lasts  a  few  days  and 
makes  the  cure  of  the  habit  difficult.  About  10  %  only  of 
the  cases  recover  and  do  not  relapse. 

Treatment. — There  are  two  remedial  methods  :  the  sudden 
or  rapid  withdrawal  of  the  poison,  and  the  gradual  method. 
Each  case  must  be  treated  on  its  own  merits,  but  the  sudden 
or  rapid  method  is  far  kinder  in  the  end,  and  should  always 
be  adopted  if  the  patient  is  under  absolute  control  in  an 
institution  or  in  an  inebriate  home.  Many  cases,  however, 
have  to  be  managed  at  home  or  in  nursing  homes,  and  then 
the  gradual  method  may  have  to  be  used.  Thoroughly 
trustworthy  nurses  must  be  engaged,  and  the  patient  should 
be  put  to  bed  and  be  carefully  watched.  No  reliance  can  be 
placed  on  his  word  as  to  whether  he  is  taking  the  drug  or  not. 
A  secret  store  may  be  utilised  and  he  will  practise  any  deception 
to  get  at  it.  Many  patients  are  treated  by  withdrawing  the 
drug  gradually,  e.  g.  a  patient,  habitually  taking  Morphia  gr.  ij 
for  each  injection,  should  be  given  gr.  j,  then  gr.  ^,  gr.  \, 
gr.  I,  and  then  it  should  be  discontinued ;  good  results  are  also 
obtained  by  giving  the  Morphia  by  suppository  gr.  \  and  gr.  \ 
before  its  absolute  withdrawal  from  the  system.  The  patient 
is  sure  to  smoke  cigarettes  all  day  during  the  treatment ; 
some  alcohol  may  be  allowed,  and  is  indeed  indicated  in  cases 
of  severe  collapse.  It  may  even  be  necessary  in  rare  cases, 
to  give  a  minute  dose  of  Morphia  by  injection,  to  tide 
him  over  for  a  time  if  the  cardiac  action  is  failing.  The 
sickness  and  diarrhoea  require  treatment  by  Sodium  Bicar- 
bonate and  stomachics,  and  Bromides  should  be  given  to 
allay  the  restlessness.  Sleep  should  be  promoted  by  giving  a 
hypnotic  at  night-time,  such  as  Chloral,  Trional,  or  Paraldehyde 
and  changing  it  each  night.  It  is  most  inadvisable  ever  to 
prescribe  Cocaine.  The  relief  gained  therefrom  is  only  at  the 
expense  of  causing  a  second  and  worse  drug  habit.  Hot 
bottles  and  good  nursing  are  necessary,  also  careful  and 
regular  feeding  with  soups  and  egg  and  milk  until  the  acute 
symptoms  subside.  The  patient  should  be  kept  under  super- 
vision for  at  least  three  months  in  order  to  restore  the  nervous 
system. 


198  MENTAL   DISEASES 


COCAINISM 


The  habit  of  taking  Cocaine  occurs  mostly  in  two  classes 
of  people.  Firstly,  in  those  who  have  had  slight  operations, 
or  throat  or  nose  troubles,  and  who  have  used  the  drug  to 
allay  irritation.  Secondly,  in  Morphia-takers  who  find  that  a 
combination  of  these  two  narcotics  produce  further  exhilarating 
effects.  As  with  Morphia,  this  drug  is  usually  taken  by  sub- 
cutaneous injection  but  occasionally  as  snuff.  It  destroys  the 
appetite  for  food,  the  patient  loses  weight,  looks  pale  and  ill. 
The  eyes  are  sunken  and  the  pupils  dilated.  He  relies  on  the 
drug  to  give  him  comfort  and  to  obtain  sleep.  It  causes  excite- 
ment with  a  feeling  of  vigour.  He  becomes  talkative  and 
brilliant,  the  association  of  ideas  being  hyperactive.  As  the 
effect  of  the  drug  passes  off,  symptoms  of  abstinence  appear 
from  auto-intoxication  by  the  natural  antidote.  The  patient 
feels  utterly  miserable,  he  is  restless  and  he  becomes  faint.  He 
is  liable  to  formication  or  other  tactile  disturbances.  He  also 
becomes  subject  to  visual  hallucinations.  The  memory  is 
affected,  and  delusions  of  suspicion  or  persecution  may  arise, 
so  that  a  patient  makes  wild  accusations  against  his  family  or 
others,  and  he  may  become  dangerous.  Cocaine  has  a  far  more 
damaging  effect  on  the  mental  constitution  than  has  Morphia^ 
and  more  cases  have  to  be  certified  as  insane.  The  symptoms 
of  abstinence  are  not  so  alarming,  but  when  recovery  has  taken 
place,  the  chance  of  relapse  is  more  probable. 

Treatment. — ^This  is  in  most  respects  similar  to  Morphin- 
ism, with  which,  moreover,  it  is  generally  associated,  but  it  is 
more  intractable.  There  is  not  so  much  danger  of  collapse  in 
suddenly  withdrawing  the  drug  in  pure  cases  of  Cocainism, 
but  the  presence  of  delusions  usually  renders  certification 
and  asylum  care  necessary.  Strychnine  is  useful  as  a  tonic 
during  convalescence. 


OTHER    INTOXICATIONS 

Ghloralism  is  now  and  then  met  with,  the  drug  having 
been  taken  nightly  by  a  patient  for  insomnia  in  increasing 
doses  over  a  prolonged  period.     As  with  Morphia  and  Cocaine, 


OTHER   INTOXICATIONS  199 

abstinence  symptoms  are  produced  by  certain  anti-bodies, 
and  a  double  intoxication  takes  place  when  large  doses  are 
taken,  so  that  definite  mental  disorder  results.  This  may 
take  the  form  of  excitement  or  depression,  and  both  visual 
and  aural  hallucinations  are  common.  There  is  also  a  state  of 
Delirium  Tremens  produced  in  some  cases,  analogous  to  that 
which  occurs  from  Alcohol. 

As  to  treatment,  the  drug  must  be  withdrawn,  and  this  is 
usually  safely  carried  out  by  a  rapid  method. 

Belladonna  {and  Atropine)  account  for  some  cases  of  mental 
disorder  due  to  poison  by  this  drug.  Children,  and  sometimes 
adults,  eat  the  berries  of  the  Deadly  Nightshade  in  mistake 
for  ordinary  Blackberries,  The  symptoms  are  Delirium  with 
visual  hallucinations  and  great  restlessness.  There  is  an 
inclination  for  stripping  off  clothing,  picking  at  imaginary 
threads,  and  other  such  movements.  Dryness  of  the  throat 
is  usual,  the  pupils  are  unduly  dilated,  and  the  accommoda- 
tion is  paralysed. 

The  treatment  consists  of  washing  out  the  stomach,  and,  as 
a  rule,  recovery  takes  place  in  a  few  days.  Some  authorities 
recommend  Morphia  or  Pilocarpine  as  antidotes  in  severe 
cases. 

Cannabis  Indica,  or  Indian  hemp,  is  taken  in  the  form  of 
Hashish  by  natives  in  the  East  to  produce  pleasurable  excite- 
ment. Active  hallucinations  of  all  the  senses  occur,  including 
the  sexual  sensations.  In  chronic  habitues,  exaltation  of 
memory  and  imagination  are  produced,  with  delusions  of 
grandeur  or  persecution,  and  a  general  moral  deterioration. 

As  to  treatment,  patients  need  asylum  care,  and  even  then 
their  recovery  as  a  rule  is  only  temporary. 

Lead  causes  Confusional  insanity,  and  the  effects  of  the 
poison  are  largely  due  to  renal  insufficiency  ;  hallucinations  are 
prominent,  and  convulsive  seizures  may  occur.  The  blue  line 
on  the  gums,  colic  and  other  physical  signs  should  enable  a 
diagnosis  to  be  made  from  General  Paralysis.  The  majority 
of  cases  recover  under  suitable  treatment. 

Salicylates  and  allied  drugs  sometimes  cause  Delirium, 
which  may  develop  into  a  transient  attack  of  excitement. 


200  MENTAL   DISEASES 

Bromides,  when  long  continued  in  large  doses,  pro- 
duce a  condition  of  lethargy  and  stupor  with  muscular  inco- 
ordination. 

Sulphonal,  Paraldehyde,  and  other  sedatives  likewise 
cause  toxic  effects  when  injudiciously  taken.  The  former 
sometimes  leads  to  hsematoporphyrinuria  with  fatal  results. 

Chloroform,  Ether,  and  other  stimulants,  taken  by 
inhalation  or  otherwise,  occasionally  cause  a  drug  habit  to  be 
formed  and  lead  to  moral  deterioration. 


CHAPTER   XVI 
CHILDBIRTH    AND    INSANITY 

Reproduction  entails  a  stress  on  the  female  sex  from  which 
the  opposite  sex  is  immune.  There  is,  however,  as  a  rule  an 
adaptation  of  the  general  health  of  the  parturient  mother 
in  the  natural  state  which,  with  the  hopeful  anticipation  in 
store,  happily  renders  this  period  one  less  susceptible  to  a 
mental  breakdown  than  is  generally  supposed.  With  the 
spread  of  civilisation,  however,  the  troubles  of  childbirth 
increase,  and  many  women  become  mentally  disordered  both 
before  and  after  labour,  and  their  attacks  are  mostly  coloured 
by  the  physiological  process  which  they  are  undergoing.  There 
is  no  definite  type  of  mental  disorder  which  can  be  described 
as  puerperal,  but  Acute  Confusional  insanity  is  most  usual; 
certain  connecting  links  must,  however,  be  mentioned  which 
are  useful  to  the  clinical  physician. 

It  is  estimated  that  about  7+  %  of  insanity  in  women  occurs 
in  connexion  with  childbirth;  viz.  1  %  during  pregnancy,  5  % 
after  delivery  and  1^  %  during  lactation. 

Inheritance  has  its  role  in  puerperal  patients  to  the  extent 
of  40  %  of  cases,  and  sometimes  there  is  a  history  of  previous 
attacks.  It  is  rather  more  common  in  apprehensive  primi- 
parse  after  the  age  of  thirty.  Illegitimacy  is  a  potent  factor, 
as  is  also  the  desertion  or  loss  of  the  husband.  Prolonged 
labour  is  more  likely  to  be  a  cause,  by  its  exhausting  effect, 
than  easy  delivery  by  forceps  skilfully  performed  with,  or 
without,  an  anaesthetic.  About  half  the  puerperal  cases  may 
be  attributed  to  septic  infection  and  auto-intoxication.  Fright 
or  shock  also  occurs  in  the  history  of  some  cases.  Mental 
disorder  may  occur  (1)  during  pregnancy;  (2)  within  a  short 
time  of  delivery;    (3)  during  lactation. 

1.  The  Insanity  of  Pregnancy  may  be  an  exaggera- 

201 


202  MENTAL    DISEASES 

tion  of  the  morbid  longings  and  caprices  that  often  occur 
at  this  period.  Moral  perversion  shows  itself  sometimes 
in  untruthfulness  and  pilfering.  It  is  associated  with 
sleeplessness,  morbid  brooding,  and  depression,  as  seen  in 
Maniacal-Depressive  insanity.  Delusions  frequently  develop 
with  aversion  towards  the  husband,  and  the  patient  may 
become  suicidal.  Mental  symptoms  occurring  before  the 
fourth  month  of  pregnancy  are  of  better  omen  than  those 
coming  on  in  the  later  months.  In  the  former  case,  recovery 
frequently  takes  place  in  a  few  weeks,  whereas  in  the  latter 
instance,  the  case  generally  continues  and  becomes  one  of 
puerperal  insanity,  but  sometimes  recovery  occurs  when  the 
child  is  born.  The  induction  of  premature  labour  or  abortion 
is  usually  not  warranted,  as  definite  mental  improvement  is 
not  commonly  occasioned  thereby,  but  it  may  be  necessary 
in  certain  cases  where  the  patient's  life  is  endangered.  It 
would  also  appear  sometimes  to  give  a  better  chance  for  the 
life  of  the  child. 

2.  Puerperal  Insanity. — Acute  Confusional  rather  than 
Maniacal-Depressive  insanity  is  what  is  most  common,  and 
Katatonic  symptoms  are  sometimes  present.  Dementia  Prse- 
cox,  and  even  General  Paralysis,  have  been  known  to  appear 
during  pregnancy  or  just  after  childbirth.  A  transitory  de- 
lirium or  an  acute  excitement  sometimes  also  occurs  at  the  time 
of  delivery  which  passes  off  a  few  hours  later  ;  the  patient  may 
be  delivered  of  her  child  in  such  a  state  and  have  no  recollection 
thereof  afterwards.  In  most  cases,  the  first  indications  of  a 
mental  breakdown  are  manifested  on  the  fourth  or  fifth  day. 
It  has  frequently  not  been  possible  to  keep  the  patient  as  quiet 
as  usual  after  delivery.  She  becomes  sleepless  and  fretful. 
She  does  not  show  natural  affection  for  the  child,  the  presence 
of  her  husband  is  a  source  of  irritation  to  her,  and  she  is  in- 
different to  her  other  relations.  She  does  not  take  her  food 
so  willingly,  and  begins  to  argue  and  quarrel  with  the  nurse. 
She  has  spectres  before  her  eyes  or  misinterprets  noises  that 
she  hears.  She  becomes  irritable  and  confused,  her  memory 
fails,  and  she  develops  morbid  fears,  and  apprehensions.  The 
patient  is  flushed,  and  has  an  anxious  look,  and  she  has  perhaps 
a  slight  rise  of  temperature,  a  rapid  pulse,  some  headache,  a  dry 
tongue  and  a  hot  skin.     The  lochia  may  be  normal,  or  they  may 


CHILDBIRTH   AND   INSANITY  203 

have  stopped.  The  breasts  may  give  trouble,  and  the  secretion 
of  milk  gradually  ceases.  The  bowels  are  costive,  and  the  urine 
is  sometimes  albuminous.  The  patient  becomes  restless  and 
impulsive  and  loses  all  self-control.  Eroticism  is  frequently 
a  marked  feature.  All  food  may  be  refused;  the  patient 
becomes  incoherent  and  acutely  excited,  presenting  a  wild 
and  unkempt  appearance.  Delusions  are  frequent  but  fleet- 
ing, while  hallucinations  are  not  uncommon.  Very  often  the 
morbid  ideas  are  of  a  religiously  exalted  character,  and  she 
imagines  she  is  the  Virgin  Mary,  or  a  persecutory  type  may 
prevail  with  hatred  towards  her  husband.  There  is  often 
change  of  identity,  and  she  calls  others  by  false  names  and 
loses  all  sense  of  orientation.  Remissions  sometimes  occur 
and  her  attention  can  be  engaged  for  a  time,  only  to  relapse, 
until  recovery  takes  place  at  the  end  of  three  to  nine  months. 
A  few  patients  die  of  exhaustion,  whilst  others  pass  into  a  stage 
of  automatic  obedience,  and  become  demented.  Cases  arising 
from  three  to  six  weeks  after  delivery  are  usually  depressed, 
with  delusions  of  unworthiness  of  a  religious  nature,  and  with 
tendencies  to  suicide. 

3.  Lactational  Insanity.— This  comprises  mental  dis- 
order which  develops  from  six  weeks  after  confinement ;  it 
usually  occurs  in  the  later  period  of  suckling  of  the  child,  and 
sometimes  it  follows  immediately  upon  weaning.  Prolonged 
lactation  causes  anaemia  and  exhaustion,  and  is  commoner 
amongst  the  poorer  classes  than  in  the  well-to-do,  and  is  no 
doubt  prompted  by  the  hope  of  preventing  early  conception. 
The  patient  becomes  restless  and  sleepless,  and  if  mental 
disorder  supervenes,  it  is  generally  of  the  nature  of  a  subacute 
depressed  form  of  Confusional  insanity,  with  ideas  of  un- 
worthiness. Delusions  are  developed,  which  often  affect  the 
husband  and  child.  Sometimes  all  food  is  refused.  There 
may  be  paroxysmal  excitement,  and  hallucinations  may  be 
present.  The  patient  looks  pale  and  ill,  and  complains  of 
various  abnormal  sensations.  There  is  a  special  tendency 
also  to  lung  complications. 

Prognosis. — Insanity  in  connexion  with  childbirth  is 
decidedly  favourable  in  all  three  kinds.  About  75  %  of  the 
cases  recover.  In  a  puerperal  case,  the  sooner  the  attack 
occurs  after  delivery  and  the  mare  acute  the  symptoms,  the 


204  MENTAL   DISEASES 

better  chance  there  is  of  complete  recovery.  A  certain  pro- 
portion of  cases,  however,  end  fatally  (10  %),  others  become 
Stuporous  and  some  of  these  eventuate  in  Dementia, 

Treatment. — In  the  poorer  classes  removal  to  an  asylum 
is  the  safest  course,  bij.t  when  means  are  sufficient  it  is  some- 
times judicious  to  avoid  certification  when  possible.  Specially 
trained  nurses  must  be  engaged,  and  the  patient  should  be  fre- 
quently visited  by  the  medical  attendant.  In  post-partum  cases 
anti-streptococcic  injections  and  vaginal  douches  may  be  indi- 
cated and  the  breasts  must  be  carefully  tended.  The  bladder 
and  bowels  should  receive  due  attention.  Refusal  of  food  may 
require  the  use  of  the  nasal  tube,  and  the  danger  of  suicide  must 
be  obviated  by  close  supervision  and  the  removal  of  all  possible 
risks.  The  child  must  be  separated  from  the  mother  at  all  costs 
and  the  husband  be  kept  away.  The  special  lines  of  treatment 
will  depend  on  the  kind  of  insanity  that  affects  the  patient,  to 
which  the  student's  attention  is  directed  elsewhere.  Caution 
must  be  used  in  giving  sedatives  to  a  pregnant  patient  so  that 
the  condition  of  the  infant  be  not  imperilled.  Lactational  cases 
especially  require  abundant  feeding  and  the  administration 
of  Iron,  Phosphates  and  other  tonics.  In  the  mild  cases  of 
the  insanity  of  pregnancy,  change  of  air  and  cheerful  surround- 
ings often  suffice,  with  the  use  of  baths  and  tonics,  the  state 
of  the  bowels  being  properly  regulated.  In  the  Stupor  that 
so  often  supervenes  in  a  case  of  puerperal  insanity,  a  course  of 
Thyroid  should  be  tried,  to  stay  the  tendency  to  Dementia. 
The  patient  should  be  kept  as  much  as  possible  in  the  open 
air,  with  abundance  of  nutritious  food,  and  a  tonic  may  be 
prescribed ;  possibly  some  alcohol  in  the  form  of  stout  may  also 
be  required.  The  patient  should  not  return  home  until  the 
menses  have  become  re-established,  and  cohabitation  should 
not  be  resumed  for  some  months  afterwards. 


INSANITY   AT   THE    EPOCHS    OF    LIFE 

Mental  diseases  vary  in  some  of  their  characteristics 
according  to  the  age  and  sex  of  the  patient ;  especially  is  a 
variation  to  be  noted  at  the  chief  epochs  of  life.  It  is, 
therefore,  useful  for  the  student  to  appreciate  and  learn  what 
are  the  main  features  of  mental  disorder  at  these  stages  of 


EPOCHAL   INSANITY  205 

life,  and  how  far  such  disorder  is  either  caused,  or  partly 
caused,  by  such  epochs,  or  in  what  way  insanity  is  likely 
to  be  modified  or  coloured  by  the  physiological  changes 
of  the  body  and  mind  that  are  indicative  of  these  times  of 
life— the  periods  of  Puberty,  Adolescence,  the  Climacteric, 
and  Senility. 

Puberty. — In  ordinary  individuals  of  Western  nations 
this  is  reached  between  the  ages  of  twelve  and  fifteen ;  any 
delay  may  be  regarded  as  a  sign  of  deficient  vitality,  and  when 
it  occurs  prematurely  it  may  be  looked  upon  as  unhealthy 
precocity,  which  frequently  forebodes  evil.  The  changes  are 
largely  the  development  of  the  sexual  characteristics  including 
the  onset  of  menstruation  in  females.  But  these  are  accom- 
panied by  other  bodily  and  mental  developments.  It  is  all- 
important  that  at  this  period  educational  methods  should 
be  specially  regulated,  and  that  there  should  be  no  forcing  of 
mental  grgwth ;  any  undue  mental  energy  should  be  held 
in  check,  and  the  physique  and  nutrition  should  receive 
every  care  and  attention.  The  brain  at  this  time  receives 
novel  impressions  from  the  reproductive  organs  which  are 
undergoing  rapid  changes  and  growth.  From  these  impres- 
sions are  derived  organic  cravings,  from  which  spring  the 
germs  of  the  higher  emotions  of  modesty  and  love.  In  the 
fresh  acquisition  of  reflexes  it  is  not  surprising  that,  in  our 
modern  civilisation,  with  the  restraints  it  imposes,  unstable 
brains  break  down  as  frequently  as  they  do.  Nature,  how- 
ever, has  endowed  the  race  with  potentialities  to  overcome 
the  incidence  of  Puberty,  the  first  strain  in  the  life  of  an 
individual,  with  comparative  freedom  from  ills.  Defective 
heredity,  when  it  shows  its  harmful  influence,  does  so  with 
greatest  surety  earlier  in  life  by  the  stunting  of  intelligence,  as 
seen  in  the  various  forms  of  Idiocy  and  Imbecility.  Epilepsy 
is  prone  to  develop,  but  Insanity  for  the  most  part  skips  the 
period  of  Puberty.  Attacks  of  Melancholia  of  the  Maniacal- 
Depressive  group  do  now  and  then  occur  in  school-girls  and 
boys,  but  they  usually  recover  in  a  short  while.  Delirious 
excitement  or  Mania  of  a  passing  nature  may  be  displayed,  or 
simply  extreme  restlessness,  aggressiveness  with  unfounded 
dislikes,  and  noisy  singing.  These  disorders  indicate  a  morbid 
strain,  and  relapses  are  to  be  expected  in  the  future  unless 


206  MENTAL   DISEASES 

prophylactic  measures  are  adopted.  During  childhood,  night 
terrors  and  convulsions  occur  in  those  of  neurotic  stock ;  and 
stammering  and  somnambulism  develop  as  their  education 
progresses.  It  is  not  altogether  uncommon  for  slight  nervous 
disturbances  to  be  revealed  during  the  stress  of  Puberty,  but 
it  is  rare  that  a  condition  of  insanity  is  seen,  and  then  the  family 
history  is  always  bad. 

Adolescence. — The  twenty-first  birthday  has  been  fixed 
by  law  as  the  time  when  a  youth  blossoms  forth  as  a  man, 
and  a  girl  becomes  a  woman.  This  is  largely  for  the  sake  of 
the  transmission  of  property,  and  may  be  regarded  as  the 
mid-period  of  Adolescence.  Although  the  reproductive  func- 
tion begins  at  puberty,  it  cannot  be  said  to  have  reached  its 
proper  development  until  the  individual  is  fully  mature, 
the  average  age  being  in  this  country  twenty-five  for  a 
man,  and  twenty-three  for  a  woman.  At  these  ages 
the  sexual  divergence  is  greatest,  the  bones  axe  consoli- 
dated, and  the  body  assumes  its  perfect  form.  The  physio- 
logical mental  changes  are  undoubtedly  greater  in  the  later 
period  of  Adolescence  than  in  the  years  following  on  Puberty, 
The  actions  and  purposes  are  different.  The  pastimes  of  boy- 
hood are  transformed  into  serious  strivings  for  the  future,  and 
ideas  of  morality  and  duty  obtrude  themselves,  whilst  the 
emotion  of  love  becomes  less  fickle  and  more  enduring.  The 
sexual  passion  now  exercises  its  full  sway,  and  demands  the 
restraining  action  of  the  higher  nerve  centres  for  its  effectual 
control.  Its  transference  into  properly  directed  energies  is 
the  transmutation  to  be  aimed  at.  Yet  many  young  men 
fall  from  the  path  of  virtue,  and  habits  of  self-abuse  or  illicit 
gratification  are  common.  At  this  time  also  criminality 
and  immorality  become  manifest,  and  in  certain  cases  puzzle 
the  lawyer  and  physician  alike.  The  mental  diseases  that 
occur  during  this  epoch  are  mostly  Maniacal-Depressive  in- 
sanity (especially  Mania)  and  Dementia  Prsecox,  but  Acute 
Delirious  Mania,  Confusiohal  insanity.  Epilepsy,  Hysteria  and 
Neurasthenia  are  also  common.  Patients  are  liable  to  short 
and  sharp  attacks,  and  they  sometimes  recover  quickly,  but 
tend  to  relapse  in  the  future.  The  sexual  tinge  in  these  cases 
is  always  marked,  and  there  is  usually  a  history  of  insanity  in 
the  family. 


EPOCHAL   INSANITY  207 

The  Climacteric. — The  suspension  of  the  function  of  the 
ovaries,  which  occurs  gradually  between  the  ages  of  forty-five 
and  fifty,  produces  various  nervous  symptoms  in  every  woman, 
such  as  flushings  and  sensations,  and  has  peculiar  mental  con- 
comitants. There  is  a  lack  of  energy  with  depression  of  spirits, 
and  occasional  weepings.  The  patient  is  aware  of  an  insidious 
change  in  her  nature,  and  life  in  general  seems  more  prosaic. 
The  facial  expression  and  bodily  form  undergo  change,  and 
sexual  characteristics  tend  to  disappear.  In  men  a  correspond- 
ing decline  in  sexual  function  occurs  a  decade  later,  viz.  between 
fifty-five  and  sixty.  Spontaneity  of  action  declines,  the  man 
tends  to  lose  interest  in  life,  he  becomes  less  active,  and 
retires  from  his  usual  occupation.  The  procreative  function 
may,  however,  continue  in  a  weakened  degree  even  unto  old 
age  in  some  men.  When  serious  mental  trouble  occurs  at  this 
epoch,  it  is  nearly  always  a  so-called  involutional  Melancholia 
closely  allied  to  that  of  Maniacal-Depressive  insanity.  In 
men,  fears  of  financial  disaster,  and  hypochondriacal  ideas 
develop.  A  suicidal  tendency  may  be  present,  but  it  is  rarely 
of  grave  account  owing  to  the  lack  of  courage  that  is  apt  to 
display  itself  at  this  time  of  life.  The  course  of  insanity  is 
usually  prolonged  at  the  menopause.  The  prognosis  in  mental 
disorder  at  this  time  of  life  is  better  in  women  than  in  men. 
many  of  whom  become  chronic,  and  some  of  whom  die. 

Senility. — Old  age  creeps  on  with  subtlety,  following  on 
the  decline  of  life  at  the  climacteric.  Threescore  years  and 
ten  has  long  been  regarded  as  the  span  of  human  life,  but  this 
bids  fair  to  be  outreached  in  the  future.  A  man  has  been  said 
to  be  as  old  as  his  arteries,  and  there  is  much  truth  in  the 
statement,  for  the  condition  of  the  circulation  is  some  index 
of  the  nutrition  of  the  brain,  and  of  the  person's  vitality  in 
general.  In  physiological  senile  decay  there  is  an  atrophy  of 
the  body,  leaving  the  face  wrinkled,  and  a  tendency  to  hernia. 
The  bones  become  brittle,  a  trip  up  on  the  carpet  being  suf- 
ficient to  cause  an  intra-capsular  fracture  of  the  neck  of  the 
femur.  The  muscles  are  flabby,  and  co-ordination  of  move- 
ments is  defective.  The  special  senses  become  blunted,  and 
cataract  is  common.  Failure  of  memory  begins  to  show  itself, 
especially  in  the  remembrance  of  proper  names.  Attention 
flags,  and  the  emotions  of  the  old  man  are  shallow  or  non- 


208  MENTAL   DISEASES 

existent.  He  talks  in  a  monotone  and  repeats  old  stories.  He 
lives  in  the  past  and  has  difficulty  in  adapting  himself  to  fresh 
conditions.  His  actions  are  slow.  He  is  apt  to  be  suspicious 
of  others.  He  is  hypochondriacal  about  his  health  and  is  unduly 
punctilious  as  to  the  state  of  his  bowels.  The  mental  affec- 
tion that  is  most  characteristic  in  old  age  is  Senile  Dementia 
{vide  p.  167),  but  Organic  Dementia  (Paralytic  insanity)  and 
Epilepsy  occasionally  occur.  Maniacal-Depressive  insanity 
(Mania  and  Melancholia)  affects  persons  at  this  time  of  life,  and 
also  Confusional  and  Paranoiac  insanity,  the  course  of  which 
it  is  difficult  to  forecast.  These  cases  sometimes  end  in  recovery 
or  partial  cure.  "A  history  of  neuropathic  taint  is  often  absent. 
The  patient  has  sometimes  indulged  largely  in  alcohol  in  earlier 
life.  At  this  epoch  also  the  sexual  instinct  occasionally  runs 
riot,  this  being  generally  due  to  the  irritation  of  an  enlarged 
prostate.  An  old  man  is  thus  sometimes  liable  to  indecent 
conduct,  or  he  makes  undesirable  attachments,  as  a  result  of 
loss  of  higher  control.  Senile  cases  are  apt  to  be  wet  and  dirty 
in  their  habits,  but  many  can  be  managed  at  home  with  trained 
nurses,  with  the  help  of  the  calming  influence  of  Sulphonal 
or  Veronal.  When,  however,  patients  are  very  noisy  or  restless 
at  night,  which  often  occurs,  an  institution  is  generally  the 
best  resort.  Refusal  of  food  should  be  dealt  with  by  coaxing 
and  persuasive  measures,  rather  than  by  forcible  tube-feeding. 


CHAPTER  XVII 
EPILEPSY   AND    INSANITY 

The  connexion  between  Epilepsy  and  Insanity  is  a  close  one. 
To  say  that  idiopathic  epilepsy  causes  insanity,  however,  is  not 
so  accurate  as  the  statement  that  the  two  affections  are  depen- 
dent on  allied  conditions  of  the  tissue  of  the  cortex  cerebri 
and  its  metabolism.  It  might  equally  be  said  that  insanity 
causes  epilepsy  in  some  cases,  for  a  small  proportion  of  chronic 
dements  first  develop  fits  towards  the  end  of  their  lives.  The 
association  is  seen  at  all  ages. 

It  has  been  computed  that  epilepsy  affects  the  general 
population  to  the  extent  of  about  ^  %,  and  that  75  %  of 
epileptics  give  indications  of  that  disease  before  the  age  of 
twenty ;  the  earlier  it  occurs,  the  more  likely  is  mental  aberra- 
tion to  arise. 

When  epilepsy  starts  in  early  childhood,  before  the  age 
of  seven,  the  underlying  brain  constitution  is  such  that  mental 
evolution  is  not  likely  to  proceed  far,  and  the  patient  will 
become  an  idiot  or  imbecile.  Epilepsy  first  manifesting 
itself  during  or  after  adolescence  may,  or  may  not,  affect 
the  mental  powers  of  the  patient,  according  to  the  type  of 
the  disorder.  An  occasional  epileptic  attack  is  indeed  com- 
patible with  intellectual  greatness,  as  the  records  of  history 
demonstrate,  for  Napoleon,  Julius  Csesar  and  others  have 
been  authentically  credited  as  having  been  subject  to  sporadic 
seizures.  It  is,  however,  doubtful  whether  such  sporadic 
seizures  should  be  regarded  as  genuine  epilepsy.  Many 
epileptics  pass  through  life  without  serious  mental  deteriora- 
tion, although  they  may  have  one  or  two  fits  a  week,  by  day 
or  during  sleep,  whilst  other  persons  become  epileptic  later 
in  life  and  show  signs  of  chronic  mental  disorder.  Usually, 
however,  the  epilepsy  has  begun  in  early  life  and  has  been  of 
long  standing.     Severity  of  the  convulsions  is  not  so  much 

P  209 


210  MENTAL   DISEASES 

an  important  indication  of  the  nerve  weakness  as  the  frequency 
of  recurrence.  The  admixture  of  petit  mal  with  ordinary 
convulsions  is  the  kind  of  epilepsy  that  is  most  prone  to  produce 
mental  symptoms  necessitating  measures  being  taken  to  place 
the  patient  under  care.  About  15  %  of  epileptics  require 
certification  as  insane. 

Hereditary  predisposition  is  generally  marked,  Epilepsy, 
Insanity,  and  Alcoholism  being  common  in  the  parents,  but 
a  blow  on  the  head  or  an  attack  of  Scarlet  fever  or  Influenza 
may  sometimes  be  the  exciting  element  which  lights  up  the 
disorder.  Stigmata  of  degeneracy  are  also  apt  to  occur  in 
the  patient,  who  may  from  childhood  have  shown  a  nervous 
temperament  with  emotionalism  and  loss  of  self-control. 
Both  sexes  are  affected  alike.  The  sexual  instinct  in  epileptics 
lacks  proper  control,  and  masturbation  is  a  common  symptom. 
The  patient  is  frequently  selfish,  morbidly  religious  and  self- 
righteous,  whilst  he  shows  little  consideration  for  others. 
When  he  becomes  insane  all  these  natural  points  are  accen- 
tuated, and  he  is  liable  to  become  one  of  the  most  dangerous 
patients  to  deal  with,  and  even  if  after  some  years  Dementia 
ensues,  he  is  not  to  be  trusted. 

Grand  Mal,  Ordinary,  or  Major  Epilepsy  is  manifested  by 
a  fit,  which  may  be  ushered  in  by  an  aura  or  warning  lasting 
from  a  few  seconds  to  two  or  three  minutes.  The  aura  is 
usually  a  sensation  in  the  epigastric  region,  but  it  may  arise 
from  the  visual  or  other  special  senses,  or  it  may  be  motor 
in  character,  consisting  of  a  definite  series  of  movements  prior 
to  the  advent  of  unconsciousness.  Patients  usually  fall  in  a 
certain  direction,  which  is  repeated  in  future  fits.  The  tonic 
spasm  lasts  about  half  a  minute.  This  may  be  accompanied 
by  a  cry  and  is  followed  by  clonic  convulsions  lasting  a 
minute  or  two,  in  which  the  tongue  may  be  bitten  and  the 
bladder  evacuated.  This  is  followed  by  stertorous  breath- 
ing and  other  signs  of  coma,  and  the  patient  usually  sleeps 
for  a  quarter  of  an  hour  or  so  before  regaining  consciousness. 

Status  Epilepticus,  in  which  there  is  a  succession  of  fits 
without  intermission,  occurs  in  about  5  %  of  cases.  It  is 
always  associated  with  pyrexia,  and  is  of  grave  omen  from 
the  exhaustion  entailed. 

Petit  Mal,  or  Minor  Epilepsy,  is  often  spoken  of  by  the 


EPILEPSY   AND   INSANITY  211 

patient  as  a  "  faint  "  or  as  a  "  sensation."  He  may  experience 
an  aura,  then  he  momentarily  loses  consciousness,  and  becomes 
pallid.  He  may  abruptly  stop  in  conversation,  or  become 
giddy  and  stumble  or  fall,  but  he  has  no  spasm  or  convulsions. 
The  nervous  discharge  in  these  cases  of  minor  epilepsy  is 
mostly  confined  to  the  association  areas,  and  does  not  affect 
the  motor  cortex. 

The  mental  disturbances  associated  with  epilepsy  are 
usually  classed  according  to  their  occurrence  shortly  before 
or  after  a  fit  :  (1)  Pre-paroxysmal  and  (2)  Post-paroxysmal 
epileptic  insanity,  or  when  no  fit  is  discernible  in  a  patient 
believed  to  be  an  epileptic,  the  mental  disorders  are  then 
usually  called  (3)  Epileptic  Equivalents  or  Masked  Epilepsy, 
e.g.  excitement,  automatism,  etc.  Lastly,  there  is  the  con- 
tinuous state  of  (4)  Epileptic  Dementia  and  (5)  Epileptic 
Idiocy  and  Imbecility . 

1.  Pre-paroxysmal  Epileptic  Insanity. — This  is  marked 
by  a  gradual  change  in  the  patient's  disposition,  a  day  or  two 
before  the  expected  fit.  He  is  moody,  more  ill-tempered  and 
impulsive  than  usual,  or  he  may  become  delusional,  or  sud- 
denly excited,  and  dangerous.  When  the  fit  takes  place,  the 
patient  frequently  wakes  up  from  it  in  his  habitual  mental 
state,  and  remains  the  same  until  the  period  immediately 
before  a  succeeding  fit. 

2.  Post-paroxysmal  Epileptic  Insanity. — Some  epilep- 
tics, after  a  fit,  develop  an  attack  of  acute  excitement  mostly  of 
a  transient  nature,  lasting  a  day  or  two ;  or  they  may  become 
depressed  or  stuporous  for  a  time.  Others  develop  delusions 
of  suspicion  and  persecution.  What  is  most  important  from 
a  medico-legal  point  of  view  is  that  the  patient  may  after 
a  fit  pass  into  a  state  of  Post-epileptic  Automatism.  This 
automatism  is  more  likely  to  happen  after  an  attack  of 
petit  mal  and  consists  of  conduct  which  has  the  appearance 
of  being  purposive,  but  of  which  the  patient  is  totally  or 
partially  unconscious.  It  often  consists  of  actions  which  are 
a  caricature  of  normal  actions.  Thus  a  patient  may  inde- 
cently expose  himself  or  commit  some  criminal  act  in  a  state 
of  irresponsibility.  This  condition  usually  lasts  only  for  a  few 
minutes,  but  it  may  continue  for  hours,  or  even  days,  after 
which  the  patient  regains  his  normal  self. 


212  MENTAL   DISEASES 

3.  Epileptic  Equivalents.— These  are  also  known  as 
psychic  or  Masked  Epilepsy  (Epilepsie  Larvee),  and  consist 
of  various  mental  disorders  in  epileptics  in  which  the  attacks 
are  unconnected  with  any  convulsion  or  petit  mal.  Thus,  in 
place  of  a  fit,  a  patient  may  have  a  violent  attack  of  transitory 
excitement,  the  most  acute  form  being  designated  Epileptic 
Furor,  the  duration  of  which  may  be  from  a  few  hours  to  a 
few  days.  Similarly,  a  patient  may  become  depressed  with 
delusions  for  a  time,  or  have  an  attack  of  Delirium,  Confusion, 
or  Stupor.  Automatism  is  also  an  important  equivalent  to 
be  mentioned,  with  more  or  less  marked  loss  of  memory,  and 
change  of  personality  or  Double  Consciousness.  Patients  take 
to  irresistible  flight,  or  make  violent  attacks,  and  even  take 
long  journeys  in  a  state  of  automatism  before  resuming  normal 
consciousness.  The  recovery  may  be  gradual  or  sudden,  and 
it  occurs  sometimes  after  sleep. 

4.  Epileptic  Dementia. — -From  10  to  15  %  of  patients  in 
asylums  are  Epileptic,  the  majority  being  more  or  less  demented. 
They  are  usually  of  low  type,  deceitful,  morose  and  querulous  ; 
outbursts  of  excitement  are  frequent,  and  they  are  degraded  in 
their  habits.  Their  physiognomy  is  characteristic.  Cicatrices 
may  be  present  on  their  heads  from  injuries  in  past  fits. 

5.  Epileptic  Idiocy  and  Imbecility. — ^This  is  mentioned 
in  the  Chapter  on  Amentia  {vide  p.  142). 

Diagnosis. — The  seizures  of  General  Paralysis  and  of 
Organic  Brain  Disease  may  be  mistaken  for  idiopathic  Epilepsy, 
and  a  careful  physical  examination  must  be  made  to  dissoci- 
ate the  different  conditions.  Hysteria  must  be  distinguished 
in  cases  occurring  early  in  life ;  the  character  of  the  fit,  the 
emotional  display,  and  general  suggestibility  usually  enable  one 
to  arrive  at  a  correct  diagnosis.  Petit  mal  must  be  distin- 
guished from  Cardiac  faints,  and  from  the  Vertigo  of  dys- 
pepsia and  cerebral  congestion. 

Prognosis. — This  is  more  favourable  in  major  than  in 
minor  epilepsy,  and  in  attacks  that  are  confined  to  the  day- 
time, or  that  occur  only  during  sleep.  The  earlier  in  life 
epilepsy  develops  the  worse  is  the  prognosis,  which  is  also 
rendered  unfavourable  by  a  history  of  cerebral  injury,  and 
by  the  advent  of  Status  Epilepticus.  Mental  disorder  is 
most    likely    to    follow   in  cases  of   frequent   recurrence    of 


EPILEPSY   AND   INSANITY 


213 


attacks  of  petit  mal  with,  or  without,  the  addition  of   major 
epilepsy. 

Pathology.- — ^The  seat  of  the  disorder  in  epilepsy  is  in  the 
highest  regions  of  the  cortex  cerebri,  the  neurons  of  which 
are  in  an  irritable  and  unstable  state  and  discharge  explo- 
sively. Scars  are  sometimes  seen  on  the  head  from  falls,  and 
the  calvarium  is  often  much  thickened.  As  has  already  been 
mentioned,  stigmata  of  degeneration  are  often  present,  and 
the  convolutions  of  the  brain  have  been  described  as  altered 
in  pattern,  or  undeveloped  in  some  cases.    Various  changes  of 


Fig.  35. — Scars  in  epilepsy. 


a  focal  nature,  blood-clots,  degenerated  nerve  cells,  and  neu- 
roglial hypertrophy,  are  found  at  times,  the  most  prominent 
being  a  sclerosis  of  the  Cornu  Ammonis.  These  changes, 
however,  by  some  observers  are  regarded  as  the  result  rather 
than  the  cause  of  epilepsy.  That  the  convulsions  are  aggra- 
vated by,  or,  are  even  due  to,  toxins  in  the  blood  as  a  result 
of  defective  metabolism  of  the  nervous  system  or  of  their 
absorption  from  the  gastro-intestinal  tract,  is  a  theory  which 
is  gaining  acceptance.  The  chief  morbid  product  found  in 
the  blood  before  and  during  a  paroxysm  is  ammonium  car- 
bamate. The  toxicity  of  the  virus  is  increased  accordingly 
after  S;  fit.     As  conviilsions  can  be  artificially  produced  by 


214  MENTAL   DISEASES 

pressure  on  the  carotid  arteries,  it  has  been  suggested  that  the 
vasomotor  system  plays  an  important  part  in  epilepsy.  It 
may  be  that  the  toxins  cause  a  constriction  of  vessels  in  certain 
cortical  areas,  with  or  without  small  thromboses,  inducing  a 
sudden  discharge  of  nervous  energy,  with  the  production  of 
convulsions. 

Treatment. — This  varies  with  the  individual  mental  dis- 
order that  the  patient  suffers  from.  An  outbreak  of  acute 
excitement  may  require  treatment  by  seclusion,  or  the  hypo- 
dermic injection  of  Hyoscine  Hydrobromate  gr.  -J-^.  Active 
supervision  is  required,  both  by  night  as  well  as  by  day,  for  those 
epileptics  who  have  suicidal  impulses,  whilst  sufficient  atten- 
dants must  be  engaged  for  a  patient  with  homicidal  tendencies. 
All  epileptics  require  watching  to  keep  them  out  of  danger, 
in  case  they  fall.  The  fireplaces  should  have  guards,  and 
stairs  should  be  specially  railed.  Bromides  are  still  the  most 
effectual  means  of  combating  the  disease,  but  they  must  be 
judiciously  administered  over  a  period  of  two  to  three  years  in 
order  to  obtain  permanent  satisfactory  results.  A  good  mixture 
consists  of  Potass.  Sod.  and  Ammon.  Bromid  aa.  gr.  x,  Sod. 
Sulphat  gr.  xx,  Aq.  Menth.  Pip.  §j  nocte  maneque,  the  dose 
being  regulated  according  to  the  case.  Liq.  Arsenicalis  TT\  ij 
may  be  added  to  each  dose  if  acne  spots  or  other  symptoms 
of  Bromism  appear.  The  bowels  must  never  be  allowed  to 
become  constipated.  As  a  rule,  only  in  confirmed  epileptics 
will  hopeful  results  be  found  wanting  from  the  use  of  Bromides. 
Should,  however,  decided  improvement  not  be  forthcoming, 
Borax  gr.  v  to  gr.  xv  should  be  added  to  the  Bromides. 
Amongst  other  drugs  that  have  been  said  to  have  done  good 
are  :  Tinct.  Belladonna,  Oxide  or  Valerianate  of  Zinc,  and 
Opium.  Zinc  preparations  particularly  are  beneficial  in  petit 
mal.  Opium  may  be  tried  in  some  early  cases  by  giving  the 
Extract,  gr.  |  in  pill,  twice  a  day  for  six  weeks,  and  then  continu- 
ing with  large  doses  of  the  Bromides,  which  in  the  course  of 
time  should  be  reduced  gradually. 

A  careful  examination  should  be  made  for  any  source  of 
peripheral  irritation,  indigestion,  eye-strain,  etc.  Any  suspicion 
of  Syphilis  should  be  cleared  up  by  Salvarsan  or  a  course  of 
Mercury.  A  localising  sign  may  lead  to  the  possibility  of 
trephining,  to  relieve  pressure. 


EPILEPSY   AND   INSANITY  215 

A  fit  may  sometimes  be  cut  short  by  the  inhalation  of  Amyl 
Nitrite,  or  by  counter-irritation  at  the  site  of  an  aura,  e.  g.  a 
strap  round  an  arm,  etc.  This  can  only  be  regarded  as  palli- 
ative, but  every  fit  that  is  prevented  tends  to  break  the  con- 
vulsive habit.  Status  Epilepticus  is  best  relieved  by  a  rectal 
injection  of  Chloral  Hydrate  gr.,  xx,  with,  or  without,  a  hypo- 
dermic injection  of  Morphia,  gr.  \.  The  diet  for  an  epileptic 
should  be  plain,  he  should  eat  sparingly  of  meat  and  take  but 
little  salt.  Alcohol  should  be  absolutely  forbidden,  and  smoking 
only  be  allowed  in  moderation.  The  patient  should  live  a  cj^uiet 
and  regular  life,  free  from  social  excitements.  Occupation 
of  an  outdoor  character  is  beneficial,  as  is  carried  out  in  the 
Colony  system.  There  is  reason  to  think  that  about  10  %  of 
epileptics  are  curable  under  careful  management,  if  treated 
early.  The  associated  mental  disorders  may  likewise  improve, 
except  in  the  case  of  the  epileptic  dement,  whose  condition  is 
hopeless  as  regards  recovery. 


CHAPTER   XVIII 

HYSTERIA    AND   INSANITY 

Hysteria  has  been  designated  a  disorder  of  the  subcon- 
scious mind ;  it  is  a  pecuHar  mental  state  in  which  the  psychical 
and  physical  symptoms  are  largely  due  to  auto-suggestion. 
When  a  case  presents  such  disordered  conduct  as  is  common 
in  insanity,  the  patient  may  require  special  treatment.  The 
laity,  unfortunately,  are  prone  to  use  the  term  Hysteria 
to  cover  obvious  cases  of  mental  derangement  in  which  no 
trace  of  the  disorder  has  ever  been  present  at  all.  Such  a 
term  leads  them  to  think  less  of  the  family  blemish  and  to 
cherish  more  hope  of  recovery.  Thus,  an  ordinary  attack 
of  Acute  Mania  in  a  young  girl  is  regarded  as  a  severe  attack 
of  Hysteria,  or  again  in  the  early  stages  of  Dementia  Prsecox, 
the  deranged  conduct  is  apt  to  be  considered  as  hysterical. 
The  physician  should  not  lend  himself  to  such  misrepresenta- 
tions. Hysteria  is  a  definite  disease,  which,  like  other  nervous 
diseases,  is  closely  allied  to,  but  is  distinct  from,  conditions 
underlying  Insanity.  The  conception  of  the  disorder  as  being 
essentially  due  to  suggestion  we  owe  mainly  to  Babinski.  The 
doctrine  of  the  splitting  of  consciousness,  the  result  of  dissocia- 
tion, has  also  been  applied  to  Hysteria ;  according  to  Breuer 
it  is  due  to  dreamlike  conscious  states  with  a  narrowed  associa- 
tive capacity ;  Janet's  view  is  that  the  subconscious  mental 
life  develops  into  a  spurious  second  personality  which  the 
retracted  conscious  self  is  unable  to  control.  Freud  ascribes  the 
subconscious  activities  of  the  disorder  as  being  due  to  repressed 
complexes  of  a  sexual  nature.  Hysterical  subjects  as  a  whole 
are  uncommon  in  asylums.  Sometimes  a  patient  suffering 
from  Intermittent  insanity  has  a  history  of  Hysteria,  or  gives 
some  indication  of  it,  during  the  attack,  but  the  two  condi- 
tions  are  for  the   most  part   distinct.     If   the   combination 

216 


HYSTERIA  AND   INSANITY  217 

Hysterical  insanity  be  used  at  all,  it  should  be  confined  to 
those  cases  of  grave  Hysteria  that  require  forcible  feeding 
and  control,  and  have  the  features  of  the  disorder  in  an  ex- 
aggerated form  so  that  their  conduct  is  quite  deranged. 

Etiology. — Hysteria  is  almost,  but  not  entirely,  confined 
to  the  female  sex  ;  it  manifests  itself  most  often  during  puberty 
and  adolescence.  At  this  period,  the  brain  has  an  increased 
infiux  of  impressions  from  the  generative  organs,  but  it  is  too 
much  to  say  that  these  organs  have  always  any  direct  etiolo- 
gical influence  on  the  condition,  as  Freud's  teaching  implies. 
Defective  heredity,  and  harmful  nurture  in  early  years,  play 
the  most  important  part  in  the  causation  of  the  disorder.  It 
is  frequently  the  outcome  of  children  being  spoilt  by  a  want 
of  discipline  in  the  parents,  together  with  irregular  hours, 
and  faulty  educational  methods.  In  predisposed  individuals 
it  may  come  on  after  some  exhausting  illness,  or  from  a  shock 
or  disappointment.  As  a  result  of  injury  it  also  occurs,  but 
it  is  then  generally  called  "  Traumatic  Neurasthenia." 

Physical  Signs. — The  bodily  health  is  not,  as  a  rule,  much 
impaired  unless  persistent  vomiting  or  refusal  of  food  occurs. 
Patients  usually  sleep  well.  The  tongue  is  clean,  but  there  is 
often  anorexia,  or  some  other  digestive  trouble.  Palpitation 
and  irregular  respiration  are  common,  together  with  the  feel- 
ing of  suffocation  (Globus  Hystericus)  that  so  many  patients 
exhibit.  Nervous  sweatings  are  frequent,  and  the  secretion 
of  urine  is  greatly  increased,  especially  after  a  convulsive 
fit.  There  are  numerous  sensory  phenomena,  e.  g.  anaesthesia, 
which  may  be  local  or  general,  or  else  confined  to  one  half  of 
the  body.  Various  hypersesthetic  areas  also  occur  over  the 
ovarian  regions,  the  spine,  or  the  lower  part  of  the  mammae, 
whilst  the  hip  and  shoulder  joints  may  be  painful  and  stiff, 
simulating  the  contractures  of  organic  disease.  The  other  special 
senses  are  also  liable  to  affection ;  one  nostril  losing  its  sense 
of  smell,  one  side  of  the  tongue  being  devoid  of  taste,  one  eye 
being  functionally  blind,  but  rarely  does  hemianopia  occur. 
Occasionally  there  is  loss  of  the  colour  sense.  The  field  of  vision 
is  invariably  contracted  as  shown  by  the  perimeter.  The 
motor  signs  are  various — paraplegia  being  the  most  com- 
mon— the  knee-jerks  are  brisk  with  a  spurious  ankle  clonus, 
and  the  plantar  reflex    is  absent.      Monoplegias    are  almost 


218  MENTAL   DISEASES 

pathognomonic,  but  hemiplegia  now  and  then  occurs.  Loss 
of  voice  is  common,  the  aphonia  in  some  instances  extend- 
ing to  absolute  mutism.  Retention  of  urine  is  somewhat 
frequent  and  a  "  phantom  tumour  "  is  sometimes  present.  In 
addition  to  paralysis,  there  may  be  various  spasms,  tremors 
and  irregular  movernents  of  a  choreic  nature. 

Hysterical  fits  consist  of  general  convulsions  which  simu- 
late Epilepsy  more  or  less,  and  sometimes  even  follow  on  an 
attack  of  petit  mal,  but  there  are  certain  obvious  distinctions 
from  an  ordinary  epileptic  fit.  The  duration  is  much  longer, 
lasting  from  a  few  minutes  to  half  an  hour  or  more.  There 
is  not  the  same  loss  of  consciousness,  and  the  patient  falls  in 
a  place  that  is  devoid  of  danger.  Instinctively  the  eyelids 
are  tightly  closed  and  the  eyeballs  are  rolled  upwards.  The 
tongue  is  not  bitten,  and  the  patient  frequently  assumes  an 
opisthotonic  state  for  a  time. 

Mental  Symptoms. — Emotional  instability  and  a  craving 
for  sympathy  are  the  most  marked  mental  traits  in  hysterical 
subjects.  Unless  there  is  great  excitement,  there  is  no  dis- 
order of  the  ideational  life.  Perception  and  memory  are 
usually  good.  Patients  are  self-centred  and  they  magnify  every 
symptom  out  of  all  proportion.  They  only  make  pretence  to 
overcome  their  condition  of  ill-health.  Their  will-power  is 
weak,  and  they  are  highly  suggestible  through  impressions  that 
fall  in  with  their  preconceived  ideas.  If  they  are  crossed  or 
contradicted,  they  become  morose  or  excited  and  make  false 
statements.  They  are  frequently  worse  at  the  menstrual 
periods,  and  may  then  be  impulsively  violent  for  a  time,  or 
have  outbursts  of  uncontrollable  laughter. 

In  order  to  call  attention  to  their  cases,  patients  will 
manipulate  the  thermometer,  and  otherwise  simulate  disease, 
whilst  self-inflicted  injuries  are  not  uncommon.  After  a  severe 
attack  there  may  be  a  state  of  Delirium  with  busy  hallucina- 
tions or  a  state  of  Stupor,  either  of  which  soon  passes  off. 
Memory  is  then  impaired,  or  even  lost.  Double  Consciousness 
occurs  on  rare  occasions,  the  one  personality  alternating  with 
another.  Hysterical  patients  are  wayward  and  erratic  in 
their  conduct.  They  are  liable  to  spasms  of  activity,  but  on 
the  whole  they  are  indolent  and  self-indulgent,  lacking  any 
purpose  in  life. 


HYSTERIA   AND   INSANITY  219 

Diagnosis. — The  absence  of  organic  disease  to  account  for 
many  of  the  symptoms  largely  points  to  Hysteria.  The  history 
of  the  patient,  together  with  former  attacks  of  a  like  nature, 
will  assist  the  physician.  The  distinction  from  Epilepsy  has 
already  received  notice. 

Prognosis. — This  is  good  in  most  cases,  provided  the 
friends  will  submit  the  patient  to  proper  treatment.  Relapses 
are,  however,  frequent.  Cases  of  many  years'  standing  rarely 
show  any  improvement,  whilst  a  fatal  issue  occurs  occasionally 
in  patients  who  persistently  refuse  food. 

Pathology. — But  little  definite  is  known  from  any  his- 
tological examinations.  The  disturbed  cerebral  function  may 
be  due  to  an  altered  state  of  nutrition  of  the  cortex,  possibly 
from  vasomotor  spasm  or  paresis.  Some  of  the  visceral 
disorders  are  no  doubt  caused  by  secondary  derangement  of 
lower  nerve  centres.  The  theory  of  the  relationship  of  the 
disorder  to  the  sexual  function  has  already  been  mentioned, 
and  that  of  neuronic  dissociation  also. 

Treatment. — Removal  from  home  surroundings  is  of  the 
first  importance.  The  relations  of  the  patient,  who  have  in 
the  past  unconsciously  done  much  to  foster  the  condition, 
frequently  regard  the  patient  either  as  suffering  from  an 
organic  disease  or  they  treat  her  as  a  malingerer.  Neither 
attitude  is  correct.  Sometimes  a  change,  with  abstention 
from  any  correspondence,  together  with  a  gradual  return 
to  regular  habits  judiciously  arranged,  is  all  that  is  required. 
Outdoor  exercise  should  be  encouraged  and  the  general  health 
be  improved  before  returning  home,  in  order  to  minimise  the 
chances  of  relapse.  In  a  severe  case  the  patient  is  best  treated 
in  bed  with  a  copious  milk  diet ;  baths  and  massage  are  also  to 
be  recommended.  Thereby  she  should  put  on  weight.  The 
physician  should  attend  regularly  and  have  a  wholesome 
controlling  influence  over  the  patient.  The  idea  of  gradual 
improvement  and  eventual  recovery  should  be  instilled 
by  every  means  of  suggestion,  and  in  this  matter  the 
nurses  can  materially  aid  in  the  treatment.  Removal  to  an 
institution  and  certification  may  be  necessary  in  some  cases, 
and  the  issue  is  usually  most  salutary.  Obstinate  refusal  of 
food  must  be  met  with  forcible  feeding,  and  the  tube  may  be 
required.   Medicinal  measures  scarcely  count  for  much,  although 


220  MENTAL   DISEASES 

the  Bromides  have  some  influence  over  the  convulsive  attacks 
and  Valerianates  occasionally  do  good.  Alcohol  in  any  form 
should  be  forbidden.  Sometimes  the  question  of  marriage 
arises,  when  the  patient  recovers.  It  should  be  discouraged 
as  a  rule,  for  the  majority  are  not  benefited  by  it.  Psycho- 
analysis has  been  adopted  in  some  cases  with  success,  by  this 
means  a  hidden  complex  may  be  discovered  and  dispersed, 
and  the  patient  be  re-educated  subconsciously  and  consciously 
to  the  normal.  In  any  case,  psychological  explanations  with 
some  patients  often  meet  mth  excellent  results,  but  they 
must  be  persisted  in  for  a  considerable  period  of  time. 


NEURASTHENIA   AND   INSANITY 

This  term  is  also  used  to  cover  many  conditions  in  which 
the  essential  element  of  this  disorder  is  absent.  Thus,  obvious 
cases  of  Melancholia  and  Hypochondriasis  often  pass  as 
Neurasthenics,  and  even  in  commencing  Paranoia,  Dementia 
Praecox,  and  General  Paralysis,  the  correct  diagnosis  fails  to  be 
made,  no  doubt  unintentionally  as  a  rule,  but  it  is  not  always 
so.  The  disorder  is  one  in  which  the  nervous  system  becomes 
morbidly  fatigued  from  inadequate  causes,  and  this  fatigue 
leads  to  a  multiplicity  of  symptoms.  It  is  frequently  asso- 
ciated with  Psychasthenia.  Other  factors  are  necessary  to 
precipitate  an  attack  of  Confusional  or  Exhaustion  insanity  in 
a  person  who  is  a  Neurasthenic. 

Etiology. — It  occurs  most  frequently  in  the  more  civil- 
ised communities,  where  the  competition  for  the  prizes  of  life 
is  keenest.  It  may  be  Congenital  or  Acquired.  The  former  is 
manifested  in  early  adult  life  when  the  individual  first  feels 
the  sense  of  responsibility.  It  is  more  common  in  males  than 
in  females.  The  predisposition  to  Neurasthenia  is  for  the 
most  part  handed  down  by  parents  who  often  have  a  history 
of  Insanity,  Alcoholism,  Syphilis,  or  Tubercular  Disease.  The 
disorder  results  from  the  patient  himself  having  at  one  time 
made  a  demand  on  his  nervous  energy  by  mental  exertion 
in  excess  of  his  capacity,  or  from  some  emotional  shock,  or 
from  some  sexual  drain,  muscular  fatigue,  or  prolonged  iUness 
whereby  the  processes  of  recuperation  have  been  interfered 


NEURASTHENIA   AND   INSANITY  221 

with.  Traumatic  Neurasthenia  is  a  nervous  disorder  mostly 
due  to  suggestion  and  should  therefore  be  regarded  as 
Hysteria. 

Physical  Signs. — The  general  nutrition  is  somewhat 
affected,  and  the  patient  is  anaemic.  The  skin  is  moist,  and 
the  extremities  cold  and  clammy.  Tremors  are  often  present 
and  the  eyelids  droop,  or  give  some  involuntary  contraction. 
The  pulse  is  small,  and  vasomotor  disorders  are  frequent.  The 
abdominal  aorta  pulsates  through  a  relaxed  abdominal  wall. 
The  spinal  centres  are  hypersesthetic.  The  knee-jerks  are 
increased,  and  nocturnal  emissions  are  often  complained  of. 
The  urine  has  sometimes  an  excess  of  phosphates.  The 
patient's  aches  and  pains  in  various  parts  of  the  body,  present 
no  physical  signs  of  disease  that  can  be  detected,  and  they 
are  probably  neuralgias  due  to  reduction  of  nerve  tension. 
In  some  instances,  patients  scarcely  look  ill  at  all. 

,  Mental  Symptoms. — The  patient  becomes  hyperaes- 
thetic,  the  special  senses  being  over  active.  He,  therefore, 
is  worse  in  a  bright  light,  he  complains  of  all  noises,  and 
orders  the  ticking  of  clocks  to  be  stopped.  There  is  nothing 
amiss  with  his  perception  or  judgment.  There  are  no  hallu- 
cinations or  delusions.  The  patient  is  depressed  to  a  certain 
extent,  but  has  a  proper  insight  into  his  state.  He  frequently 
is  emotional  and  bursts  into  tears,  or  is  irritable  and  excited. 
Very  rarely  is  his  conduct  so  much  affected  that  certificates 
of  insanity  are  requisite.  The  majority  are  for  ever  referring 
to  their  ailments,  complaining  of  inability  to  think,  and  of 
pressure  on  the  head,  or  of  various  symptoms  referable  to  the 
eyes,  the  spine,  and  the  visceral  or  sexual  organs.  They  are 
liable  to  contract  the  bed  habit  as  their  volition  is  weak.  They 
become  fatigued  on  the  least  exertion,  mental  or  bodily. 
Sleep  is  not  usually  much  interfered  with. 

Diagnosis. — As  has  already  been  mentioned.  Hypochon- 
driacal Melancholia  and  several  other  conditions  are  frequently 
mistaken  for  Neurasthenia.  It  must  be  granted  that  a  mixed 
state  is  often  present,  but  the  second  malady  must  on  no 
account  be  overlooked.  Especially  is  this  necessary  in  the 
recognition  of  early  signs  of  General  Paralysis,  Cerebral 
Syphilis,  Intra-cranial  Tumours,  Tabes  Dorsalis,  Disseminated 
Sclerosis,  Graves's  Disease,  etc.    A  careful  physical  examination 


222  MENTAL   DISEASES 

is  absolutely  necessary  in  every  case  presenting  symptoms  of 
nervous  exhaustion.  Hysteria  should  be  distinguished  by 
its  anaesthesias,  its  functional  paralyses,  and  other  symptoms 
due  to  auto-suggestion. 

Prognosis. — This  is  better  in  the  Acquired  than  in  the 
Congenital  cases ;  that  is  to  say,  a  patient  suffering  from  the 
result  of  emotional  shock  or  of  some  exhausting  process,  will 
improve  sooner  than  one  in  whom  the  whole  malady  is  due 
to  hereditary  transmission  of  nerve  weakness,  in  which  any 
slight  strain  is  productive  of  symptoms.  The  outlook  is  better 
also  where  the  circumstances  are  easy,  and  where  there  is  no 
struggle  to  maintain  a  position.  The  malady  is,  however,  one 
in  which  relapses  are  common,  and  in  later  life  it  becomes 
chronic.  Rarely,  however,  does  it  lead  to  an  attack  of 
Exhaustion  insanity. 

Pathology. — Nothing  has  been  demonstrated  by  morbid 
anatomy.  The  nerve  centres  are  in  a  condition  of  irritable 
weakness  from  malnutrition,  probably  owing  to  katabolic 
activity  being  in  excess  of  anabolism. 

Treatment. — Prophylaxis  is  of  the  first  importance.  The 
children  of  nervous  parents  require  special  upbringing.  Later 
in  life  occupations  should  be  sought  in  which  freedom  from 
stress  and  competition  may  be  hoped  for.  When  the  symptoms 
of  Neurasthenia  are  urgent,  a  modified  rest  cure  is  the  best 
indication  for  improvement,  after  the  method  of  Weir  Mitchell 
^^ — say,  for  a  month  or  six  weeks.  The  patient  should  abstain 
from  all  letter-writing,  and  should  be  placed  in  the  care  of 
nurses,  and  after  a  time  he  should  be  encouraged  to  get  up, 
and  occupy  himself.  Tonics  and  a  course  of  feeding  up,  with 
electrical  applications  and  massage,  are  productive  of  much  good 
in  many  cases.  Valerianates  and  other  drugs  are  sometimes 
given  without  much  benefit,  but  should  the  patient  be  sleepless 
or  very  restless,  sedatives  become  necessary.  The  physician 
should  endeavour  to  gain  the  confidence  of  his  patient,  and  as 
improvement  occurs,  travelling  is  to  be  recommended.  Out- 
door pastimes  should  be  encouraged,  provided  that  the  patient 
does  not  tax  his  energies  too  far.  Some  chronic  cases  have  to 
live  away  from  home  surroundings  and  become  boarders  in 
asylums  or  hydropathic  establishments  where  the  hours  are 
regular,  and  the  general  routine  is  beneficial  to  them. 


PSYCHASTHENIA   AND   INSANITY  223 


PSYCHASTHENIA  AND  INSANITY 

A  certain  number  of  persons,  in  whom  the  affecting  disorder 
is  one  of  uncontrollable  ideas  or  actions,  come  under  the 
observation  of  every  physician  who  devotes  himself  to  nervous 
and  mental  diseases.  The  patient  is  often  painfully  conscious 
of  his  state.  Some  idea  constantly  recurs,  and  dominates 
his  mental  being.  He  is  beset  with  a  certain  fixed  idea, 
which  is  usually  accompanied  by  a  strong  emotional  bias. 
His  will-power  is  weakened  (Abulia),  he  is  the  victim  of  an 
obsession,  i.e.  of  a  compulsive  or  imperative  idea,  which  may 
be  described  as  a  mental  tic,  and  which  interferes  with  his 
mental  equilibrium.  Sometimes  a  past  moral  offence  haunts 
the  patient,  or  he  may  have  irrepressible  fears,  the  result  of 
some  unconscious  psychic  trauma.  He  may  be  the  victim  of 
indecision  or  doubt  as  to  his  actions,  or  if  the  idea  is  one 
which  especially  tends  to  action  in  which  deliberation  plays  no 
part,  he  is  said  to  suffer  from  impulses.  Many  come  within 
the  range  of  the  so-called  "  Border-line  "  cases,  and  the  sanity 
or  insanity  of  the  individual  in  question  is  largely  dependent 
on  the  nature  of  the  idea  or  action  in  question,  and  on  the 
extent  to  which  the  will-power  is  genuinely  impaired.  The 
pronounced  cases  are  sometimes  termed  cases  of  Volitional 
Insanity,  Obsessional  Insanity,  Impulsive  Insanity,  Hesitating 
Insanity,  or  Folie  du  Doute.  Psychasthenia  often  occurs  with 
Neurasthenia,  and  is  also  associated  with  many  varieties  of 
insanity.  It  is  a  morbid  exaggeration  of  an  anomalous 
condition  that  exists  in  many  persons  who  are  otherwise 
normal,  such  as  the  involuntary  repetition  of  certain  phrases 
or  tunes,  and  the  liability  to  various  habits  and  tricks  which 
are  difficult  to  overcome,  but  which  do  not  interfere  with 
their  life's  work.  These  include  the  various  motor  tics  and 
habit  spasms.  Closely  allied  are  those  cases  given  to  morbid 
blushing  and  shyness. 

Etiology. — There  is  usually  a  history  of  family  instability, 
and  the  condition  is  accentuated  by  bodily  illness  and  any 
source  of  fatigue. 

Physical  Signs. — Patients  are  sometimes  so  worried  that 
they  pass  sleepless  nights ;    the  appetite  fails,  and  they  lose 


224  MENTAL   DISEASES 

weight.  The  special  senses  are  as  a  rule  very  alert  and  the 
deep  reflexes  are  exaggerated. 

Mental  Symptoms. — The  primary  bases  of  perception, 
thought,  memory  and  attention  may  all  be  normal.  There 
is  also  no  weakening  of  intellectual  operations  in  many  cases, 
but  the  association  of  ideas  is  narrowed  and  dominated  by 
some  outstanding  idea,  of  which  the  tone  of  feeling  is  such 
as  to  prevent  the  transmission  of  the  idea  to  other  ideas,  and 
as  a  consequence  it  constantly  appears  above  the  threshold  of 
consciousness.  The  ideas  that  thus  recur,  and  cause  mental 
aberration  are  usually  those  causing  a  morbid  feeling  of  appre- 
hension or  dread.  Thus,  there  is  the  fear  of  open  spaces 
(Agoraphobia),  the  fear  of  closed  spaces  (Claustrophobia),  the 
fear  of  heights  (Acrophobia),  the  fear  of  dirt  (Mysophobia), 
the  fear  of  the  dark  (Nyctophobia),  the  fear  of  Syphilis 
(Syphilophobia),  the  fear  of  infection  (Nosophobia),  the  fear 
of  diarrhoea  (Coprophobia),  the  fear  of  travelling  by  train, 
stage  fright,  etc.  Some  patients  are  in  a  state  of  constant 
indecision,  and  are  everlastingly  re -writing  their  letters,  or 
unsealing  them  from  their  envelopes  to  make  sure  of  what  is 
witMn.  They  have  to  reassure  themselves  many  times  over 
that  the  gas  is  turned  off,  or  that  the  doors  are  bolted  at  night. 
Some  patients  are  always  in  a  state  of  perpetual  doubt.  They 
feel  they  come  to  a  wrong  decision  about  very  simple  ques- 
tions, even  as  to  matters  of  dress,  which  they  frequently 
change  many  times  a  day.  They  have  a  clear  insight  into 
their  state,  they  realise  the  uin:easonableness  of  their  actions, 
they  try  to  restrain  themselves,  but  experience  considerable 
distress  in  their  attempts.  They  suffer  from  paralysis  of  will- 
power, which  the  recurring  obsession  overmasters.  Amongst 
those  subject  to  morbid  impulsive  actions  must  be  mentioned 
cases  of  Kleptomania — the  obsession,  or  rather  the  impulse, 
to  steal  artifcles — theft  often  of  a  useless  kind ;  Pyromania — to 
burn  haystacks,  etc. ;  Dipsomania — the  recurring  and  over- 
powering desire  to  drink  {vide  p.  194).  Sometimes  patients,  in 
whom  there  is  no  other  indication  of  insanity,  voluntarily 
place  themselves  under  care  for  a  tendenc}'  to  Suicidal  or  to 
Homicidal  impulses. 

Diagnosis. — This  presents  no  difficulty.  There  is  but 
little  emotional  or  intellectual  disorder;    the  conduct  of   the 


PSYCHASTHEXIA  AXD   IXSAXITY  225 

patient,  however,  is  such  that  not  mfrequently  certification 
is  necessary. 

Prognosis. — This  depends  on  the  length  of  time  the 
patient  has  been  allowed  to  drift  without  treatment.  If  a 
year  or  two  have  elapsed,  it  is  more  than  probable  that  the 
condition  is  chronic,  but  in  recent  cases  recovery  is  the  rule. 

Pathology. — It  is  suggested  that  a  weakened  state  of 
health  in  a  predisposed  individual  so  disturbs  the  higher 
cortical  neurons  as  to  interfere  with  inhibitory  action,  or 
according  to  Janet  as  to  produce  '"'  a  lowering  of  the  psycho- 
logical tension."  Freud's  sexual  theory  is  also  applied  to 
Psychasthenia — his  belief  being  that  the  condition  is  due 
to  a  transference  of  the  "  affects  "  from  morbid  subconscious 
complexes. 

Treatment. — This  consists  in  regulating  the  daily  life  of 
the  patient  so  that  his  attention  is  diverted  as  much  as  possible. 
If  the  bodily  health  is  run  down,  plenty  of  rest  should  be 
enjoined,  and  he  should  be  placed  on  a  nutritious  diet  with 
vegetable  tonics.  The  daily  visit  of  the  medical  man  has  an 
encouraging  influence  over  the  patient,  and  his  converse  with 
him  helps  to  disperse  his  troubles.  Some  anxious  cases  need 
institution  care,  recovery  in  recent  attacks  frequently  occurring 
after  a  few  months,  whilst  in  others  improvement  only  can  be 
expected.  Hypnotism  has  been  vaunted  by  some,  but  its 
use  has  not  proved  reliable  as  a  rule ;  on  the  other  hand,  many 
cases  obtain  relief  by  psycho-analytical  methods,  persistently 
and  scientifically  carried  out  and  the  patient's  mind  trained 
by  re-education  {vide  p.  315).  Psychological  persuasion  and 
suggestion,  however,  form  the  main  sheet-anchor  for  the 
successful  treatment  of  the  disorder,  a  method  which  has  been 
extended  recently,  especially  by  Dubois. 


CHAPTER   XIX 

GENERAL   DISEASES    AND   INSANITY 

Insanity  in  every  case  is  assumed  to  be  dependent  on 
physical   disease   or   disorder,    the   central    seat   of  which   is 
located  in   the   cortex    of  the  brain.     By  mental   disease  is 
inferred  bodily  disease  in  so  far  as  cerebral  affection,  func- 
tional or  organic,   is   the  substratum,  even  if  the  lesion  is 
microscopical  or  is  due  to  biochemical  changes  only.     It  remains 
now   to   consider   briefly   some   other  bodily   diseases   (apart 
from  brain  tumours,  etc.)  that  clinical  experience  teaches  us 
as  having  a  special  causal  relationship  to  insanity,   and  to 
specify  the  types  of  mental  disorder  associated  with  them. 
It  should  be  noted  by  the  student,  that  every  disease  has  more 
or  less  influence  on  the  mental  functions  of  the  patient,  and 
has,   therefore,   a  mental  aspect.     Illness  is  a  drain  on  the 
nervous  system  which  affects  the  mental  functions  to  some 
extent,  and  produces  insomnia,   inattention,   irritability,   de- 
pression, and  a  weakening  of  the  higher  faculties.    Some  of 
the  more  important  correlative  conditions,  however,  demand 
special  notice.     A   distinction   must   also   be   made   between 
affections  having  an  etiological  relationship  to  insanity,  and 
those  diseases  that  the  insane  are  particularly  liable  to. 

Influenza. — This  is  the  most  common  infection  that  causes 
mental  disturbance  and  post-febrile  insanity.  In  some  patients, 
especially  young  persons,  a  temporary  Delirium  may  be  set 
up  during  the  invasion,  but  even  after  the  subsidence  of 
bodily  symptoms,  a  general  state  of  depression  remains, 
sometimes  with  suicidal  tendencies.  This  may  culminate 
in  an  attack  of  Confusional  insanity  with  intense  excite- 
ment, noisiness,  hallucinations,  disorientation,  insomnia  and 
refusal  of  food;  the  patient,  perhaps,  passes  into  a  state  of 

226 


GENERAL   DISEASES   AND   INSANITY  227 

deep  depression  with  delusions,  or  becomes  Stuporous,  before 
recovery  takes  place.  The  influenza  bacillus  has  a  weak- 
ening influence  on  the  nervous  system,  no  doubt  due  to 
toxins,  and  although  the  febrile  attack  may  not  be  severe, 
the  disease  is  apt  to  cause  serious  mental  disturbance  in  un- 
stable persons.  Persons  usually  get  well  after  a  few  months, 
but  the  continuance  of  hallucinations  is  of  bad  omen.  Plenty 
of  nutritious  food  is  of  paramount  importance  in  the  treatment 
of  influenzal  insanity,  and  sedatives  should  not  be  withheld, 
if  insomnia  persists.  The  patient  should  be  kept  under 
adequate  supervision,  especially  in  the  state  of  severe  depres- 
sion that  often  supervenes  in  such  a  case.  General  Paralysis 
is  sometimes  attributed  to  Influenza,  but  the  explanation  is 
that  the  Influenza  is  only  a  contributory  factor. 

Septicsemia,  Scarlet  Fever,  Enteric  Fever,  and 
Smallpox  are  infective  conditions  that  occasionally  cause 
a  serious  mental  breakdown.  The  disorder  is  generally  of 
the  Confusional  type  when  the  fever  subsides,  but  occasion- 
ally a  Delirious  attack  occurs  at  the  outset. 

Rheumatic  Fever. — In  some  cases,  the  Delirium  of  the 
fever  may  pass  into  acute  excitement,  and  the  joint  affections 
disappear.  Anti-rheumatic  remedies  should  be  persevered 
with.  Occasionally,  a  change  of  moral  disposition  is  to  be 
noticed  after  Acute  Rheumatism,  without  any  pronounced 
mental  symptoms  at  all. 

Malaria  causes  a  chronic  depression  in  some  persons,  and 
a  few  cases  of  acute  excitement  have  also  been  recorded. 
Quinine  is  in  all  cases  indicated. 

Diabetes. — Depression  with  apprehensiveness  and  irrita- 
bility is  usually  met  with.  Dietetic  regime  almost  invariably 
leads  to  improvement.  Although  the  disease  occurs  in  neurotic 
families,  it  is  seldom  that  even  transient  glycosuria  occurs  in 
ordinary  insanity. 

Gout. — Irritability  is  generally  expected  in  the  gouty 
subject,  and  it  is  frequently  accompanied  by  mental  depres- 
sion, especially  in  the  mornings.  Sometimes  an  attack  of 
Intermittent  Melancholia,  or  rarely  one  of  Mania,  develops, 
and  the  physical  disorder  ceases.  Thus  a  metastasis  occurs 
in  this  metabolic  disorder,  which  has  led  to  the  term  "  Sup- 
pressed   Gout."     The    bowels    require    active    attention,  and 


228  MENTAL   DISEASES 

the  patient  must  be  guarded  from  suicidal  tendencies.    Most 
cases  may  be  regarded  as  hopeful. 

Bright 's  Disease. — In  Ursemic  conditions,  patients  are 
in  a  state  of  mental  wandering,  with  active  hallucinations, 
especially  of  sight.  They  are  restless  and  agitated,  besides 
being  liable  to  twitchings  and  convulsions.  The  prognosis 
is  bad.  In  ordinary  cases  of  high  blood  pressure  associated 
with  albumen  and  casts  in  the  urine,  there  is  chronic  depression, 
which  treatment  by  saline  purges  alleviates. 

Syphilis. — The  poison  of  this  specific  disease,  as  regards 
the  mental  functions,  affects  persons  in  a  variety  of  ways. 
Some  patients  pass  through  attacks  of  Intermittent  insanity 
in  which  a  syphilitic  history  plays  no  part.  In  others  Syphilis 
attacks  the  membranes,  neuroglia,  and  vessels  of  the  brain, 
producing  Confusional  insanity  and  Organic  Dementia,  the 
former  being  fairly  curable  under  the  influence  of  Mercury 
and  Iodide,  or  Salvarsan.  These  conditions  are  invariably 
accompanied  by  headache,  and  sometimes  by  ocular  or  other 
palsies,  or  by  a  seizure.  They  develop  as  a  rule  within  the 
first  five  years  after  infection.  The  relation  of  Syphilis  to 
Idiocy  and  Imbecility  has  been  already  mentioned  {vide  p.  147). 
Occasionally,  in  the  secondary  stage  of  the  disease,  the  fever 
has  been  known  to  pass  into  a  condition  of  Acute  Confusional 
excitement  of  short  duration,  ending  in  complete  recovery. 
In  some  patients  of  a  mild  Paranoid  character,  the  eruptions, 
especially  when  on  the  face,  have  been  the  means  of  developing 
delusions  that  people  are  staring  at  them,  etc.  Syphilophobia 
has  already  been  referred  to  under  Psychasthenia ;  most  patients 
in  this  category  have  never  contracted  Syphilis  at  all,  whilst 
others  who  have  been  cured  of  their  infection,  become  depressed 
and  suicidal,  with  a  dread  of  spreading  the  disease  to  others. 
Locomotor  Ataxy  is  occasionally  associated  with  curable 
insanity,  but  when  mental  symptoms  arise  in  Tabes,  it  is 
generally  a  part-process  of  General  Paralysis,  both  of  which 
are  regarded  as  Para-syphilitic  affections. 

Phthisis. — Tuberculosis  and  Insanity  are  often  associated 
in  the  same  stock,  one  member  of  a  family  dying  of  Phthisis, 
whilst  another  becomes  insane.  Many  of  the  insane  die  of 
Tubercle  in  asylums  (over  1800  per  annum),  whilst  a  few 
phthisical  subjects  develop  mental  disease.     The  hopefulness 


GENERAL   DISEASES   AND   INSANITY  229 

generally  associated  with  the  sane  consumptive  is  then  usually 
replaced  by  a  gloomy  depression  with  ideas  of  suspicion 
and  refusal  of  food.  The  prognosis  is  invariably  bad,  the 
mental  disorder  in  no  way  arresting  the  progress  of  the  lung 
destruction. 

Heart  and  Lung  Disease. — Cyanosis  is  sometimes  accom- 
panied by  definite  mental  symptoms  in  old  people.  There  is 
usually  Delirium  or  Confusion  with  hallucinations  and  vague 
fears,  passing  into  Coma.  Pneumonia  sometimes  causes 
Delirium  which  passes  into  insanity.  Aortic  disease,  when 
associated  with  insanity,  is  more  frequently  attended  with 
excitement,  and  Mitral  disease  with  anxious  depression. 

Abdominal  Disease. — Gastro-intestinal  disorder  is  usually 
productive  of  Hypochondriasis  and  gloomy  depression.  Oc- 
casionally a  growth  or  ulcer  may  be  the  localising  factor  in  the 
development  of  a  delusion.  Movable  kidney  causes  symp- 
toms of  distress  in  some  people,  involving  pain  and  mental 
depression,  but  these  are  usually  alleviated  by  the  use  of  a 
renal  pad. 

Pelvic  Disease. — Utero-ovarian  trouble  is  at  times  the 
exciting  cause  of  insanity.  The  cessation  of  the  menstrual 
functions  is  productive  of  mental  disorder  in  some  patients, 
but,  on  the  other  hand,  in  many  more  the  amenorrhcea  is 
brought  about  by  an  attack  of  insanity.  Prostatic  or 
Bladder  trouble  causes  insomnia,  and  is  occasionally  looked 
upon  as  a  factor  in  the  mental  breakdown  of  old  age. 

Disease  of  the  Thyroid. — In  Myxoedema  the  thyroid 
secretion  is  deficient  with  mental  hebetude,  which  in  some 
cases  amounts  to  insanity.  There  is  sluggishness  of  thought 
and  action,  and  the  memory  is  sometimes  affected.  Occasion- 
ally fretfulness  and  irritability  exist,  with  fleeting  delusions. 
All  the  mental  symptoms  show  remarkable  recovery  under  the 
administration  of  thyroid  extract.  The  patient  should  be  kept 
in  bed,  on  small  doses  at  first,  viz.  the  equivalent  of  gr.  iij  of 
the  fresh  gland  once  a  day.  The  dose  is  gradually  increased, 
the  pulse  and  temperature  being  noted.  Any  undue  rise  of  the 
pulse  or  temperature,  coupled  with  headache  and  tremors, 
indicates  that  the  amount  of  thyroid  must  be  diminished.  A 
graduated  dose  of  thyroid  is  necessary  for  the  rest  of  the 
patient's   life,   otherwise  relapse  will   occur.     Cretini&m  is    a 


230  MENTAL   DISEASES 

defective  condition,  physical  as  well  as  mental,  dependent 
on  the  congenital  absence  or  deficiency  of  the  Thyroid.  In 
its  severest  forms  it  causes  Idiocy  {vide  p.  147),  but  the  milder 
cases  (Cretinoids)  are  of  the  Imbecile  type.  In  this  country  it 
occurs  sporadically,  but  it  is  endemic  in  certain  goitrous  dis- 
tricts abroad.  The  'Cretin  grows,  and  improves  physically 
under  the  regime  of  thyroid  feeding  (as  a  rule  gr.  v  to  x  of 
the  extract  may  be  given  per  diem),  but  not  much  mental 
improvement  is  to  be  expected,  if  treatment  has  been  delayed 
until  after  the  age  of  four  years.  Change  from  the  neigh- 
bourhood is  advisable  to  a  district  where  the  drinking  water 
is  free  from  chalk  and  iron.  Exophthalmic  Goitre  is  probably 
due  to  excessive  thyroid  secretion.  The  disorder  occurs  in 
neurotic  families,  and  there  is  often  a  history  of  shock  or 
worry.  Most  patients  are  generally  in  a  state  of  dread ;  when 
insanity  ensues.  Acute  Confusion  is  the  most  usual  form  of 
mental  disorder,  and  although  improvement  occurs,  relapses 
are  frequent,  ending  in  a  chronic  delusional  state.  The  prog- 
nosis is,  therefore,  unfavourable  in  spite  of  anti-thyroidic  and 
X-ray  or  electrical  treatment. 

Pellagra. — This  affection,  which  is  not  uncommon  in 
Italy,  was  formerly  thought  to  arise  from  eating  bread  made 
from  diseased  maize.  It  is  probably  due  to  some  organism 
which  Sambon  alleges  to  have  its  habitat  in  streams.  The 
disease  is  characterised  by  skin  affections,  diarrhoea,  and 
spinal  sclerosis,  and  in  certain  cases  also  by  mental  depres- 
sion and  excitement  with  confusion,  and  frequently  leads  to 
a  fatal  issue.  Occasional  examples  have  been  reported  in 
Scotland  and  in  this  country. 

Chorea. — This  disorder,  which  is  much  more  common  in 
children  than  in  adults,  is  usually  accompanied  by  mental 
symptoms  of  a  mild  nature,  such  as  dulness,  inattention,  and 
loss  of  memory.  Acute  Confusional  excitement  occasionally 
supervenes  on  Chorea,  in  which  case  the  choreic  movements 
cease,  and  the  patient  usually  recovers  after  a  few  weeks; 
in  pregnant  women  an  attack  of  Chorea  is  sometimes  followed 
by  mental  depression.  In  the  hereditary  progressive  malady 
(Huntingdon's  Chorea),  depression  with  mental  deterioration  is 
almost  invariable. 

Paralysis  Agitans. — This  disease  is  accompanied  in  the 


GENERAL  DISEASES   AND   INSANITY 


231 


Fig.  36. — Myxosdeiua. 


232  MENTAL   DISEASES 

majority  of  cases  by  chronic  depression,  slowness  of  thought 
and  vague  dreads,  so  that  occasionally  certification  is  necessary. 
Similar  mental  symptoms  are  sometimes  associated  with  Dis- 
seminated Sclerosis,  and  also  with  the  Occupation  Neuroses. 

Sunstroke. — Insolation  as  a  cause  of  insanity  is  with- 
out doubt  much  exaggerated  by  the  laity.  Most  cases  of 
mental  disease  occurring  in  the  tropics  are  attributed  to  the 
sun  without  sufficient  warrant.  It  is,  however,  possible  that 
heat  hyperpyrexia  may  occasionally  cause  Mania  in  a  person 
predisposed  to  Maniacal-Depressive  insanity,  and  it  un- 
doubtedly tends  to  aggravate  and  accelerate  the  symptoms 
of  General  Paralysis. 

The  Insane,  and  Bodily  Disease.— The  student  will 
learn  from  his  clinical  visits  to  asylums  that  the  insane  enjoy 
a  measure  of  immunity  from  some  ailments,  whilst  they  are 
more  prone  to  others.  The  average  death  rate  in  insane 
persons  is  certainly  high,  being  more  than  six  times  that  of 
the  outside  population.  It  is  rare  to  find  an  Acute  Maniac 
catching  cold  or  developing  Pneumonia,  in  spite  of  exposure, 
whilst  a  Melancholiac  with  his  shallow  respiration  tends  to 
Pulmonary  disease  and  is  practically  always  troubled  with 
constipation  and  its  attendant  disorders.  Phthisis  is  unduly 
prevalent  in  the  chronic  cases  of  public  asylums.  It  has 
a  death-rate  which  is  quite  as  high  as  that  due  to  General 
Paralysis,  if  not  higher.  Nervous  Diseases  (Epilepsy,  Cerebral 
Apoplexy,  and  Thrombosis,  etc.),  Old  Age,  Pneumonia,  Heart 
Disease,  Bright's  Disease  and  Arterio-sclerosis  come  next  in 
the  list.  Ulcerative  Colitis,  or  Dysentery  of  an  infectious 
nature,  is  also  common  in  some  of  the  larger  institutions, 
and  it  requires  isolation,  and  special  treatment  by  antiseptic 
enemata,  and  feeding  on  bland  nutritious  liquid  diet.  As 
has  already  been  mentioned,  Senile  and  General  Paralytic 
cases  are  liable  to  fractures  from  slight  falls.  In  the  latter 
disease  there  is  a  remarkable  power  of  recuperation,  ulcers 
and  bedsores  healing  up  in  the  last  stages,  when  least  ex- 
pected. Skin  affections,  such  as  sebaceous  and  pigmentary 
anomalies,  occur  frequently  amongst  the  insane.  Finally, 
it  is  to  be  noted  that  a  bodily  disease  is  often  the  means 
of  improving  and  sometimes  of  curing  an  otherwise  doubt- 
fully recoverable  mental  case.    Thus,  an  attack  of  Erysipelas 


TRAUMATISM  AND   INSANITY  233 

or  Eczema  has  been  known  to  arrest  an  attack  of  Melan- 
cholia, and  to  lead  to  its  cure.  In  the  same  way  the  adminis- 
tration of  Thyroid  in  Stupor  and  Chronic  Melancholia  is 
often  beneficial. 


TRAUMATISM  AND   INSANITY 

The  effect  of  injuries  to  the  skull,  and  of  accidents  in  general, 
are  not  such  as  can  be  said  to  loom  to  any  great  extent  in 
the  complicated  causes  of  insanity.  A  history  of  a  blow  on 
the  head  at  some  time  is  not  uncommon,  but  on  probing  the 
matter,  its  significance  does  not  bear  the  importance  that  the 
relatives  are  apt  to  accord  it.  Cases  of  injury  to  the  head, 
in  which  mental  disturbance  supervenes,  are  mostly  those 
arising  from  Concussion,  and  only  rarely  are  they  of  such 
duration  as  to  give  rise  to  a  condition  of  insanity.  It  is 
remarkable  that  in  most  persons,  lesions  of  the  brain  and  its 
membranes,  with  or  without  fracture  of  the  skull,  should 
happen  with  such  little  permanent  mental  defect.  Cases 
do  occur,  however,  sometimes  of  alteration  of  character,  and 
of  change  of  desires  and  of  conduct,  in  persons  who  have 
sustained  some  injury  to  the  head.  Lapses  of  memory  are 
frequent,  and  patients  are  prone  to  become  confused,  impulsive 
and  irritable.  The  severity  of  the  injury  has  apparently  no 
bearing  on  the  case.  When  a  head  injury  is  accompanied  by 
prolonged  mental  disturbance  amounting  to  Confusional 
insanity,  the  patient  has  frequently  been  Alcoholic,  but  in 
any  case  such  injury  generally  renders  him  susceptible  to  the 
overpowering  influence  of  stimulants,  and  he  should  become 
an  abstainer. 

Most  authorities  are  agreed  that  there  is  no  definite  type 
of  what  is  sometimes  called  "  Traumatic  Insanity,"  and  injury 
to  the  head  must  be  regarded  as  rare  in  the  production  of 
insanity.  Neither  is  there  anything  distinctive  in  the  case, 
which  is  also  rare,  of  mental  disorder  after  a  surgical  operation. 
It  is,  moreover,  a  question  whether  the  operation  itself,  or 
the  anaesthetic,  is  the  main  feature  in  the  etiology  of  a  case 
of  so-called  Post-Operative  Insanity.  It  is  usually  of  a 
Confusional  type. 


234  MENTAL   DISEASES 

An  injury  to  the  head  is  likely  to  light  up  any  tendency  to 
an  attack  of  Intermittent  insanity  or  of  Paranoia  in  a  patient 
predisposed  thereto  by  Heredity  or  Alcoholism.  It  is  a  factor 
sometimes  in  the  production  of  Delirium  Tremens. 

It  is  also  possible  for  trauma  to  be  an  agent  in  the  accelera- 
tion of  the  symptom,s  of  General  Paralysis,  but  it  cannot  be 
said  to  be  anything  but  a  contributory  cause  of  this  disorder. 
Mental  and  motor  disturbance  after  a  blow  on  the  head,  in 
many  cases,  means  that  the  subject  is  a  General  Paralytic,  and 
that  the  injury  has  rendered  the  disorder  more  pronounced. 
Again,  with  regard  to  Epilepsy  and  its  psychical  disorders,  a 
certain  commotion  of  the  cerebral  centres  from  a  blow  on  the 
head  may  just  be  the  exciting  factor  in  starting  the  tendency 
to  recurrent  explosive  attacks,  but  the  neuropathic  taint  is 
present  to  produce  such  a  result,  whether  there  be  an  organic 
foundation  for  the  disorder  or  not.  Injury  to  the  infant's  skull 
is  likely  also  to  cause  arrest  of  mental  development  {vide  p.  146). 
Injury,  alleged  to  produce  mental  disorder,  may  be  of  other 
parts  of  the  body  as  the  result  of  accident,  and  not  of  the  head 
at  all.  In  this  event,  the  condition  rarely  amounts  to  insanity. 
When  symptoms  arise  without  obvious  physical  disorder, 
directly  after,  or  within  a  short  interval  of  the  alleged  accident, 
there  has  usually  been  some  emotional  shock  connected  with  it. 
These  are  the  functional  cases  which  are  commonly  called 
"  Traumatic  Neurasthenia,"  and  which  are  so  difficult  to  gauge, 
now  that  the  question  of  compensation  under  modern  legisla- 
tion has  become  regularised.  A  nervous  disorder  is  indubitably 
present,  which  is  mostly  Hysteria,  and  which  is  aggravated  by 
legal  proceedings.  Often,  no  improvement  takes  place  until  a 
settlement  is  arrived  at.  Undoubtedly,  a  loophole  is  left  for 
malingering,  which  requires  close  scrutiny,  and  the  physician 
should  be  most  careful  in  his  examination  of  the  patient  to 
detect  signs  of  fraud.  Most  of  these  cases  are  due  to  auto- 
suggestion, and  they  require  treatment  of  an  appropriate 
nature. 


CHAPTER   XX 
THE    PATHOLOGY    OF    INSANITY 

The  Brain  being  the  organ  for  the  executive  of  what  we 
know  as  Mind,  it  is  natural  that  the  student  should  expect  to 
find  morbid  changes  within  the  skull  in  cases  of  insanity. 
These  exist,  but  not  always  to  the  extent  that  might  be  sup- 
posed from  a  casual  examination,  and  from  a  comparison  with 
an  average  normal  brain  from  the  accident  ward  of  a  general 
hospital. 

In  some  cases,  the  cerebral  changes  are  indefinite  as  regards 
a  naked-eye  examination,  and  sometimes  the  microscopic 
appearances  are  not  typical.  In  others,  however,  for  instance, 
in  pronounced  Idiocy,  in  General  Paralysis,  and  in  Senile  and 
other  Dementias,  the  pathological  changes  are  self-evident. 
The  student  will  find,  moreover,  that  degenerative  processes 
not  infrequently  also  occur  in  other  regions  of  the  body,  some 
of  which  indicate  generalised  disease,  and  must  be  regarded 
as  factors,  in  a  measure,  assisting  the  disorganisation  of  brain 
functions,  whilst  others  are  secondary  to  the  cerebral  disorder, 
and  have  little  or  no  influence  on  the  cerebral  processes. 
The  association  of  the  thyroid  gland  with  cerebral  processes, 
for  instance,  is  particularly  marked,  as  the  student  has  already 
learnt  when  considering  Cretinism  and  Myxcedema. 

The  pathology  of  mental  diseases  is  still  in  its  infancy, 
but  active  research  is  in  progress,  which  is  yearly  adding  to 
our  knowledge.  In  this  country  the  advance  is  largely  due 
to  the  work  of  Mott,  and  others  are  also  doing  good  work  in 
this  direction. 

The  student's  study  of  Psychology  will  have  taught  him 
that  the  symptoms  of  insanity,  so  frequently  met  with  in  the 
shape  of  disturbed  emotions  and  delusions,  can  have  but  little 
physical  counterpart  in  a  post-mortem  inquiry,  however  real 

235 


236  MENTAL   DISEASES 

they  may  be  in  the  living  subject.  When,  indeed,  focal  lesions 
are  found  independently  of  the  special-sense  and  sensori- 
motor areas,  abnormal  mental  symptoms  arise  from  defective 
action  of  the  association  or  intrinsic  neurons,  which  pervade 
the  entire  cortex,  but  are  specially  represented  in  the  association 
areas  of  the  brain.     • 

When  morbid  changes  are  restricted,  as  occasionally 
happens,  to  a  localised  portion  of  these  areas,  the  entire  range 
of  mental  operations  is,  nevertheless,  not  infrequently  in- 
volved. Moreover,  the  constitution  of  a  nerve  cell,  both 
molecular  and  chemical,  is  so  complex  that  functional  changes 
within  the  cell  require  more  subtle  means  of  investigation  than 
are  at  present  at  the  disposal  of  the  pathologist.  As  might 
be  expected  in  insanity,  the  cortex  is  the  part  of  the  brain 
chiefly  affected;  the  white  matter,  basal  ganglia,  cerebellum, 
pons  and  medulla,  presenting  a  fairly  normal  appearance  in 
many  cases.  The  thalamus,  also,  which  is  so  intimately 
connected  with  affective  states,  might  be  expected  to  show 
more  morbid  changes  than  it  usually  does. 

As  is  the  case  in  general  Medicine,  the  changes  that  are  most 
obvious,  are  those  that  occur  in  chronic  conditions ;  whilst 
in  acute  disorders,  the  alteration  in  the  tissues  is  ill-defined. 

The  student  has  already  been  taught  how  to  prepare  sections 
of  nerve  tissue.  In  asylum  laboratories,  Formalin  (10  %)  is 
used  as  a  hardening  agent  and  a  portion  of  about  |  to  1  c.mm. 
of  cortex  is  immersed  therein  for  about  ten  da^^s.  After 
subsequent  washing,  it  is  passed  through  spirit  for  forty-eight 
hours  and  then  embedded  in  photoxylin  and  mounted  on 
pieces  of  wood.  Specimens  are  left  in  spirit  for  subsequent 
section  by  the  microtome.  Films  of  cerebro -spinal  fluid  are 
prepared  by  hardening  in  Alcohol  (after  centrifuging),  and  are 
embedded  and  momited  in  the  same  way,  and  stained  with 
Pappenheim's  (pjAronin-methyl  green)  solution. 

It  has  been  said  that  the  origin  of  mental  diseases  will 
not  be  further  advanced  by  maldng  microscopic  sections  of 
brain  tissue,  that  thereby  the  ravages  of  disease  only  are  shown, 
and  that  no  clue  to  causation  is  possible  by  histological  means. 
This  is  true  in  a  limited  sense,  when  such  examinations  are 
made  with  no  reference  to  clinical  histories.  A  comprehensive 
pathology  should  embrace  chemical  investigation,  as  well  as 


THE   PATHOLOGY   OF   INSANITY  237 

other  means  of  research,  not  only  of  the  brain  and  its  invest- 
ments, and.  of  the  cerebro-spinal  fluid,  but  also  of  the  blood, 
and  of  the  other  organs  of  the  body.  Moreover,  such  investi- 
gation should  be  taken  in  conjunction  with  a  personal  history 
of  the  patient  and  his  immediate  forbears,  together  with  the 
study  of  any  outstanding  special  environmental  influences. 

These  latter  have  already  been  discussed  in  the  Chapter  on 
Causation,  and  it  is  here  proposed  to  refresh  the  student's 
memory  with  certain  anatomical  and  other  data,  and  briefly 
to  consider  further  than  has  been  possible  under  the  separate 
psychoses,  the  morbid  changes  in  insanit}^  that  are  to  be 
observed  in  the  brain  in  general,  and  in  the  cortex  in  particular. 
The  chemistry  of  nervous  metabolism  is  still  obscure,  although 
our  knowledge  in  that  direction  is  progressing.  The  investiga- 
tion of  the  electrical  variations  in  nerve  currents  has  not  taught 
us  as  much  as  was  at  one  time  expected,  and  so  far,  this 
knowledge  has  had  no  application  to  the  study  of  psychiatry, 
although  the  galvanometer  has  been  used  by  some  observers 
for  investigating  emotional  states. 

The  macroscopic  appearance  of  the  brain  of  an  ordinary 
healthy  person  should  show  but  slight,  if  any,  injection  of  the 
cortex.  Hypersemia  occurs  chiefly  in  Acute  Delirious  Mania 
and  some  other  acute  conditions  of  insanity.  Not  much 
reliance  should  be  placed  on  the  presence  of  venous  congestion, 
which  is  usually  found  in  post-mortems.  The  adult  brain 
should  weigh  approximately  49  oz.  and  44  oz.  in  the  male 
and  female  sexes  respectively,  and  it  diminishes  as  old  age 
approaches  by  about  1  oz.  per  decade. 

The  brain  weighs  about  12  oz.  at  birth,  and  about  30  oz. 
at  the  end  of  the  first  year,  the  male  brain  being  generally 
heavier  than  the  female  from  the  beginning.  In  starvation 
the  brain  scarcely  wastes  at  all,  but  in  chronic  insanity  there 
is  sometimes  marked  shrinkage,  dependent  on  cortical  de- 
generation and  atrophy.  By  separating  the  cerebellum,  pons 
and  medulla  from  the  cerebrum,  it  is  useful  to  compare  the 
combined  weight  of  the  former  three  bodies  with  the  weight 
of  the  brain  as  a  whole.  In  a  normal  brain  the  proportion 
should  be  about  one  to  eight,  whereas  in  many  asylum  cases 
it  is  one  to  six,  thus  showing  what  degree  of  cerebral  atrophy 
obtains,  the  atrophy  being  mostly  due  to  cortical  affection. 


238 


MENTAL  DISEASES 


In  General  Paralysis  the  brain  usually  shows  vascular 
injection,  and.  there  is  marked  wasting  of  the  convolutions, 
particularly  in  the  frontal  and  parietal  lobes,  the  sulci  easily 
falling  apart.  The  cortex  is  diminished  in  thickness,  sometimes 
by  a  third.  The  pia-arachnoid  is  thickened,  milky  and  opaque, 
and  when  stripped  from  its  surface,  it  frequently  takes  minute 
portions  of  the  cortex  away  with  it.  There  is  excess  of 
cerebro -spinal  fluid,  the  white  matter  is  abnormally  shiny 
on  section  and  localised  softenings  may  occur  here,  as  well 
as  in  the  grey  matter.     Collections  of  fluid  can  sometimes 


Fig.  37. — Hemisphere  in  dementia,  showing  cortical  atrophy  and  width  of  sulci. 

be  seen  through  the  pia-arachnoid  on  the  surface  of  the 
brain.  Sometimes  with  the  naked  eye,  the  arterioles  may  be 
seen  to  be  tortuous  and  sprouting,  and  the  perivascular  spaces 
to  be  enlarged  and  fllled  with  debris.  The  ventricles  are 
dilated,  and  their  ependyma  has  a  frosted  appearance,  especi- 
ally in  the  fourth  ventricle. 

The  coloured  illustration.  Frontispiece  (Fig.  1),  is  from 
an  actual  specimen,  showing  the  appearance  of  the  brain  in 
pronounced  General  Paralysis. 

In  Dementia,  especially  in  Senile,  but  also  in  some  Alcohohc 
cases,  there  is  atrophy  of  the  convolutions  (Fig.  37) ;  some 


THE   PATHOLOGY   OF   INSANITY  239 

demented  brains,  indeed,  closely  resemble  those  of  General 
Paralysis,  although,  as  a  rule,  the  changes  are  not  so  complete. 
Cortical  affection  is,  however,  most  marked  in  profound  Amen- 
tia. The  association  areas  are  congenitally  deficient,  the  entire 
cortex  is  thin  in  many  cases,  and  the  brain  as  a  rule  is  small. 
In  severe  cases  of  Idiocy  the  arrest  of  development  is  extreme, 
and  the  cortex  is  scarcely  convoluted  at  aU  (Fig.  38).  Very  occa- 
sionally, an  abnormal  cavity  (porencephaly)  exists  in  one  of  the 
hemispheres,  the  result  of  a  haemorrhage  at,  or  shortly  after, 
birth.  Other  anomalies  may  also  be  present.  In  Hypertrophic 
idiocy  the  brain  may  be  much  increased  in  size  and  weight 
from  overgrowth  of  neurogha,  and  in  Hydrocephalus  there  is 
an  enormous  amount  of  cerebro -spinal  fluid.     In  Systematised 


Fig.  38. — Brain  in  profound  amentia. 
Weight  8  oz.     (jVIicrocephalic  idiocy.) 

Delusional  insanity  there  is  sometimes  an  atypical  arrangement 
of  convolutions,  and  microgyria,  or  subsulci  may  exist.  In 
Mania,  Melancholia  and  Confusional  insanities  (including  some 
due  to  Alcoholism),  in  which  a  fatal  issue  has  resulted,  the 
macroscopic  changes  are  usually  indefinite,  unless  a  process 
of  Dementia  has  supervened. 

The  consistence  and  chemical  composition  of  the  brain 
alter  to  some  extent  in  conditions  associated  with  insanity. 
An  analysis  of  the  normal  brain  shows  the  presence  of  (1) 
Lipoids — Lecithin,  etc.;  (2)  Proteins;  (3)  Extractives;  and 
(4)  Inorganic  constituents — salts  and  water.  As  adult  age 
is  reached,  the  lipoids  increase  and  the  other  constituents 
decrease.  In  General  Paralysis,  Dementia  Prsecox,  and  other 
Dementias,  the  lipoids  are  decreased. 


240 


MENTAL  DISEASES 


The  Neurons. — The  histological  structure  of  the  normal 
cortex  cerebri  has  already  been  briefl}^  referred  to  {vide  p.  25), 
and    further   consideration   must    now    be   given   thereto   in 


Normal. 


Amentia. 


Fig.  39. 


Dementia. 

( Diagrammatic. ) 


comparing  it  with  the  appearance  of  the  cortex  in  pronounced 
mental  diseases.  The  grej  matter  is  almost  wholly  composed 
of  neurons  or  nerve-cells  and  their  processes.  These  processes 
are  composed  of  dendrons  and  axons,  and  represent  the  tan- 
gential and  radial  fibres  which,  in  the  deeper  laj'ers  of  the 


1st  layer. 


■lud  layer. 


3rd  layer. 


4th  layer. 


5th  layer 


\  ■■   f     •- 


■:■■  ■/'.  i  \<u,-iT- 


■■-.  .-L'-af. 


i  s 


A'      i' 


la 


Fig.  40. — -Strip  of  motor  cortex  in         Fig.  41. — -Strip  of  motor  cortex 
general  paralysis,   showing    loss  in  general  paralysis,   showing 

of  nerve   fibres  and  increase  of  degeneration     of     nerve    cells 

capillaries.    (Weigert-Pal  x  45.)  and   perivascvilar   infiltration. 

(Nissl  X  45.) 

[To  face  paf/e  2-11. 


THE   PATHOLOGY   OF   INSANITY  241 

cortex,  form  a  complex  reticular  network.  The  other  elements 
are  the  blood  capillaries,  lymph  channels,  and  occasional 
neuroglia  cells  and  fibres.  The  afferent  cortex  is  receptive 
by  means  of  subcortical  (thalamic)  neurons,  the  axons  of 
which  communicate  molecular  discharges,  probably  through 
the  granular  layer  of  the  cortex,  to  the  dendrons  of  its  intrinsic 
or  association  pj^amidal  cells.  The  axons  of  these  in  turn 
fuially  connect  with  the  dendrons  of  the  motor  projection 
neurons  of  the  efferent  cortex,  through  the  axons  of  which 
energ3^  tends  to  be  discharged.  The  pathological  changes  in 
the  cortex  in  insanity  mostly  consist  of  imperfect  develop- 
ment, partial  or  complete  destruction,  or  premature  decay, 
of  these  association  neurons.  Their  sjnaptic  connexions, 
which  Hnk  together  the  afferent  and  efferent  paths  in  the  cortex, 
are  essentially  the  seat  of  mental  operations.  The  morbid 
processes  begin  in  the  supra-granular  pyramidal  nerve  ceUs, 
and  affect  the  nerve  processes  secondarily.  There  are  changes 
to  be  noted  in  the  neuroglia  and  the  blood-vessels,  and  there 
is  an  altered  composition  of  the  cerebro-spinal  fluid.  These 
changes  occur  also  in  the  primary  efferent  neurons,  especially 
in  General  Paralysis,  and  are  best  exemphfied  in  the  giant 
Betz  cells  which  exist  in  the  emissive  portion  of  the  Frontal 
lobe,  and  they  are  to  be  noted  in  the  larger  and  smaller 
pyramidal  nerve  cells  which  pervade  the  cortex,  and  subserve 
the  intellectual  life.  In  extreme  cases  the  pryamidal  nerve 
cells  are  completely  atrophied  and  the  tangential  and  radial 
nerve  fibres  disappear.  These  pathological  defects  are 
markedly  shown  in  Amentia  and  Dementia,  which  the-  fore- 
going diagram  (Fig.  39)  serves  to  illustrate. 

Figs.  40  and  41  are  drawings  of  strips  of  motor  cortex 
taken  from  a  case  of  General  Paralysis.  The  diminution 
and  distortion  of  the  pyramidal  nerve  cells  are  marked, 
together  with  proliferation  of  vessels  and  perivascular  cellular 
infiltration,  and  atrophy  of  the  tangential  and  radial  nerve 
fibres.  They  should  be  compared  with  the  drawings  of  strips 
of  the  normal  motor  cortex  facing  p.  25  (Figs.  12  and  13). 

In  emotional  states  such  as  occur  in  recent  or  acute  attacks 
of  Mania  and  Melancholia,  and  in  many  cases  of  Confusional 


242  MENTAL   DISEASES 

insanity,  the  changes  in  the  cortex  are  less  obvious,  amounting 
perhaps  to  cloudj^  swelling  of  the  nerve  cells  which  is  onl}^  of  a 
functional  nature  and  capable  of  reparation,  but  in  chronic 
cases,  when  Dementia  is  manifested,  the  nerve  cells  exhibit 
degenerative  changes. 

A  nerve  cell  nourishes  itself  by  the  imbibition  of  the  sur- 
rounding lymph,  and  accumulates  a  store  of  latent  energy  to 
be  used  when  required.  This  potential  energy  is  high  in 
healthy  individuals,  but  is  low  in  those  from  an  insane  stock, 
in  whom  cortical  metabolism  is  defective.  The  nerve  cells 
discharge  explosive^  or  irregularly,  and  morbid  changes 
result,  leading  to  permanent  degeneration.  The  association 
nerve  cells  belonging  only  to  one  group  or  system  may  be 
implicated,  others  escaping  by  reason  of  their  higher  vitality, 
and  possibly  performing  partially  the  functions  of  those  that 
are  destroyed. 

The  most  effective  staining  methods  for  demonstrating 
changes  in  nerve  cells  and  fibres,  are  the  methylene  blue 
of  Nissl  for  the  former,  and  the  Weigert-Pal  (hsematoxylin) 
for  the  latter.  Making  comparisons  between  sections  taken 
from  normal  brains,  and  from  brains  of  the  chronic  insane, 
and  discounting  errors  due  to  post-mortem  appearances  and 
artifacts,  the  following  pathological  changes  may  be  mentioned. 
The  nerve  cell,  as  it  fails  in  vitality",  becomes  cloudy  and  begins 
to  swell.  This  is  probablj'^  due  to  osmosis,  and  it  encroaches 
on  the  cavity  in  which  it  lies  surrounded  by  its  nutrient  lymph. 
The  nerve  cell  alters  in  shape  and  becomes  rounder.  The 
chromatoplasm  composing  the  Nissl  bodies  gets  broken  up, 
and  the  granules  are  finally  disintegrated  into  a  fine  dust 
(chromatolysis),  those  at  the  periphery  of  the  cell  being  usually 
first  affected.  The  delicate  fibrils  of  the  matrix  become 
similarly  broken  up  (achromatolysis),  and  take  the  stain  more 
readily  than  they  do  normally.  The  nucleus  of  the  cell  alters 
in  contour,  is  less  distinct,  falls  to  the  periphery,  and  so 
becomes  eccentrically  placed  from  lack  of  support.  Vacuola- 
tion  of  the  cell  occurs  as  the  matrix  disappears.  The  axon 
and  dendritic  processes  (or  dendrons)  of  the  cell  become 
varicose,  then  shrivel  and  finally  disappear  as  the  cell  atrophies. 
Thus  a  homogeneous  unstained  mass  results,  and  ultimately 
a  granular  scar  is  left.  Surrounding  the  nerve  cell  the 
lymphatic  space  is  enlarged,  and  it  contains  many  satellites. 


Xucleus. 


© 


6 


W  ©       #■ 


® 


Phagocyte. 


O 


o 


f;t 


Q 


% 


t 


Vaciiolalidi 


Fig.  42.— Stages  of  degeneration  in  nerve  cells,  showing  also 
phagocytosis.     (XissI  x  400.) 


[To  face  par/a  24:2. 


THE   PATHOLOGY   OF   INSANITY    ,  243 

These  are  mostlj^  glia  cells,  and  are  concerned  with  the 
absorption  of  the  retrograde  products  and  waste  debris  which 
choke  np  the  space  from  destructive  metabolic  action.  The 
accompanying  illustrations  (Fig.  42)  should  be  compared  with 
the  normal  nerve  cell,  facing  p.  24  (Fig.  11). 

These  pathological  changes  occur  in  greater  or  less  degree 
in  the  nerve  cell,  when  its  nutrition  is  impaired  from  various 
causes.  From  excessive  stimulation  of  the  nerve  cell,  its 
metabolism  may  be  so  much  affected,  and  its  energy  (both 
potential  and  actual)  so  reduced  by  fatigue  products  as  to 
prevent  proper  oxygenation.  The  normal  biochemical  inter- 
change between  the  nerve  cell  and  the  surrounding  lymph  or 
cerebro-spinal  fluid  is  disturbed,  and  its  reserve  oxygen  and 
organic  basis  are  encroached  upon.  Defective  stimulation 
has  likewise  a  destructive  influence  on  the  nerve  cell. 

More  commonly  these  appearances  are  due  to  blood  condi- 
tions, such  as  Anaemia  or  Hypersemia,  Local  or  General, 
Primary  or  Secondary,  and  more  especially  to  the  existence 
of  toxins.  These  toxins  may  be  introduced  from  without  (Exo- 
genous), or  maybe  engendered  within  the  body  (Endogenous). 
The  former  include  Alcohol,  Microbic  and  other  poisons,  the 
latter  are  not  so  easily  specified,  their  composition  being 
unknown  to  a  great  extent.  Amongst  these  may  be  mentioned 
toxins  produced  in  the  cortex  itself  as  the  result  of  morbid 
metabolism,  others  from  the  Liver  and  Intestinal  tract  the 
result  of  faulty  digestion  and  constipation,  and  others  again 
from  various  parts  of  the  body,  but  especially  from  altered 
hormones  or  internal  secretions  of  the  ductless  glands.  Orr 
and  Rows  have  demonstrated  also  the  possibility  of  infection 
of  the  spinal  chord  and  brain,  from  septic  foci  in  remote  parts 
of  the  body,  by  means  of  the  lymph  system,  in  the  sheaths  of 
nerves. 

Although  the  processes  and  fibres  of  cortical  nerve  cells 
are  only  secondarily  affected  in  degenerative  changes,  it  is 
possible  that  toxins  may  have  a  selective  influence  on  the 
synapses.  These  synapses  exist  at  the  terminal  arborisations 
in  the  hypothetical  receptive  substance,  where  probably  active 
metabolic  processes  occur,  and  where  possibly  even  toxins 
may  be  produced  in  neuropaths. 

The    Neuroglia. — This   consists    of   delicate   connective 


244  MENTAL   DISEASES 

tissue,  composed  of  glia  cells  with  branching  processes  and 
fibres,  which  stain  readily  by  the  Weigert  process.  It  forms 
the  supporting  or  protective  system  for  the  nervous  elements. 
From  the  ventricles  of  the  brain,  fibres  pass  in  a  radial 
direction,  frequently  branching,  and  finally  ending  under  the 
pia  mater  of  the  convolutions  ;  the  other  fibres  are  prolonga- 
tions of  processes  of  glia  cells.  Glia  cells  vary  considerably 
in  size,  some  being  mere  granules,  whilst  others  give  rise  to 
the  Deiter's  or  so-called  Spider  or  Scavenger  cells.  The  latter 
are  somewhat  sparsely  interspersed  normally  in  the  cortex, 
but  undergo  marked  proliferation  in  certain  conditions, 
especially  in  General  Paralysis  and  Senile  Dementia. 

Glia  cells  have  each  a  nucleus  and  nucleolus,  and,  as  in- 
sisted on  by  Bevan  Lewis,  have  a  phagocytic  action,  removing 
inflammatory  detritus  by  sweeping  it  into  the  lymph  channels, 
and  devouring  the  refuse  of  degenerated  neurons.  Frequently 
a  glia  process  is  seen  attached  to  a  capillary  or  to  a  nerve  cell. 
With  the  Nissl  stain  the  glia  cell  processes  scarcely  show,  and 
therefore  they  are  apt  to  be  mistaken  for  leucocytes  and 
lymphocytes  surrounding  a  decaying  nerve  cell.  As  neurons 
degenerate  and  atrophy,  so  glia  cells  and  their  processes  and 
fibres  proliferate,  possibly  from  the  non-absorption  of  nutrient 
lymph  by  the  nerve  cells.  Eventually  in  chronic  cases  a 
sclerosis  supervenes,  due  to  increase  of  neuroglia  tissue.  A 
certain  degree  of  gliosis  has  been  described  in  the  deeper 
layers  of  the  cortex  in  Dementia  Prsecox.  Overgrowth  of 
neuroglia  to  a  remarkable  extent  is  to  be  observed  in  Hyper- 
trophic idiocy.  It  also  occurs  independently  of  actual 
insanity  in  the  so-called  gliomatous  tumours  which  frequently 
become  hsemorrhagic.  Glia  cells  surrounding  an  atrophying 
nerve  cell  may  be  so  abundant  as  to  block  the  lymphatic 
space  almost  entirely.  There  is  also  a  similar  infiltration, 
and  choking  with  glia  cells  and  some  leucocytes  in  the  lymph 
spaces  and  in  the  sheaths  around  the  blood-vessels.  These 
characteristics  are  very  marked  in  some  advanced  Dementias, 
especially  in  Senile  and  Alcoholic  Dements,  whilst  they  occur 
in  an  exaggerated  degree  in  General  Paralj^sis.  In  the  last- 
mentioned  disease,  Ij^mphocytes  and  plasma  cells  are  also  present 
in  the  lymphatic  sheaths,  and  rod  cells  (and  mast  cells)  are  like- 
wise to  be  seen.  There  is  some  doubt  as  to  the  origin  of  these 
plasma  cells  and  rod  cells ;    the  former  are  probably  altered 


t'ij 


^ 


^ 


^. 


■^x?>,      ^ 


o.' 


0 


A  (-^-K 


Plasma 
cells. 


Hod 
cells. 


Fig.  43. 


(Nissl) — Glia  cells — (Weigert). 


(X  500.) 


Fig.  14. 

Granulations  on  the  floor  of  fourth  ventricle. 

(Semi-diagi-ammatic  X  50.) 

[To  face  paf,e  244 


THE   PATHOLOGY   OF   INSANITY  245 

endothelial  cells,  the  result  of  proliferation  in  the  lining  of  the 
blood-vessels  in  General  Paralysis,  and  are  only  to  be  seen  in 
this  disease,  in  Cerebral  Syphilis,  and  in  Sleeping  Sickness. 

The  Gerebro-spinal  Fluid. — This  consists  normally  of 
a  clear  saline  liquid  (NaCl),  which  is  faintly  alkaline,  and  is 
devoid  of  ordinary  albumen,  and  therefore  does  not  coagulate 
on  boiling,  but  contains  globulin,  and  traces  of  urea  and  dex- 
trose. It  should  be  almost  entirely  free  from  corpuscular 
elements.  Its  specific  gravity  is  about  1006,  and  probably 
from  100  to  150  c.cm.  are  secreted  in  the  twenty-four  hours. 
It  changes  rapidly  after  death.  In  atrophic  brain  conditions, 
and  especially  in  General  Paralysis,  there  is  considerable 
excess  of  fluid  to  be  found  at  a  post-mortem,  in  comparison 
with  the  escape  of  such  liquid  from  a  normal  brain.  In  Hydro- 
cephalus, the  amount  of  fluid  may  be  enormous.  The  pressure 
is  variable,  being  about  140  to  150  mm.  of  mercury,  but  in 
General  Paralysis  it  may  be  200  mm.  or  more.  It  is  secreted 
by  the  epithelium  lining  the  Choroid  plexus  of  the  lateral  and 
fourth  ventricles,  and  circulates  at  each  cardiac  systole  through 
the  foramen  of  Majendie,  into  the  central  spinal  canal,  and  also 
escapes  through  the  sub-arachnoid  spaces,  and  along  the 
Ijonphatics  accompan^dng  the  glosso-pharjmgeal  and  other 
cranial  nerves,  and  along  the  spinal  nerve  roots.  It  is  probably 
absorbed  again  together  with  the  lymph  that  bathes  the  nerve 
cells,  by  the  venous  spaces,  and  so  enters  the  superior  longitu- 
dinal sinus,  by  means  of  the  lymph  channels  and  perivascular 
sheaths  of  the  cortical  arachnoid  and  dura  mater,  and  from  the 
spinal  region  possibly  by  means  of  the  thoracic  duct.  It 
undoubtedly  escapes  at  times  into  the  naso-pharynx,  and  is 
therefore  liable  to  infection  in  diseased  conditions.  The 
cerebro -spinal  fluid  acts  as  a  protective  cushion  to  the  brain, 
filling  up  all  spaces  and  minimising  shocks  to  the  nervous 
system.  It  also  resembles  lymph  in  its  functions,  and  is  the 
medium  of  exchange  between  the  blood  and  nervous  tissue 
in  metaboHc  processes,  the  acid  products  of  which  become 
neutralised.  Its  chemical  composition  has  been  investigated 
especially  by  Mott,  who  finds  an  excess  of  cholin  in  General 
Paralysis,  due  to  products  of  degeneration.  This  body — 
cholin — arises  from  the  hydration  of  lecithin  (protagon), 
a  phosphoretted  lipoid  (fat),  which  becomes  split  up  in  this 


THE   PATHOLOGY   OF   INSANITY 


247 


as   it   is   apt   to    be   forgotten    when  he    leaves   his  medical 
school. 

The  Arteries  are  derived  from  the  Internal  Carotids  and 
the  Basilar  (the  latter  resulting  from  the  union  of  the  Verte- 
brals).  From  the  former  are  given  off  the  anterior  and  middle 
cerebral  arteries,  and  from  the  latter  the  posterior  cerebral 
arteries.  The  two  anterior  cerebrals  communicate,  as  do  also 
the  middle  and  posterior  cerebrals,  forming  the  circle  of 
WiUis. 

Anterior  cerebral.      Internal  carotid.      Middle  cerebral. 


Posterior 
communicating. 


Basilar. 


Vertebral. 
Fig.  46. — Diagram  of  the  arteries  of  the  brain. 

Each  of  the  anterior,  middle,  and  posterior  cerebral  arteries 
divides  into  two  separate  systems  of  branches,  viz.  central 
and  peripheral.  The  former  supply  the  basal  ganglia  and  white 
matter,  the  latter  supply  the  pia  mater  and  cortex ;  and  there 
is  no  communication  between  these  two  systems.  The  former 
are  strictly  terminal  vessels,  and  do  not  anastomose  with  one 
another.  The  latter  divide  into  small  arterioles  which  ramify 
in  the  pia  mater  and  enter  the  cortex  vertically,  some  of  them 
penetrating  for  a  short  distance  into  the  subjacent  white 
matter. 


248 


MENTAL  DISEASES 


The  Capillaries  form  a  dense  network  in  the  cortex,  which 
is  extremely  well  supplied  with  blood,  the  chief  vascular  area 
being  the  mid-zone  of  the  grey  matter,  in  fact,  the  latter  may 
almost  be  likened  to  a  sponge  soaked  in  blood. 

The  Veins  of  the  cerebrum,  as  well  as  the  Sinuses,  possess 
no  valves,  and  are  devoid  of  any  muscular  coat.  On  leaving 
the  brain  tissue  and  pia  mater,  the  veins  enter  and  become 
continuous  with  the  sinuses  between  the  layers  of  the  dura 
mater,  their  junction  being  in  an  opposite  direction  to  the 
blood-current.     They  may  be  divided   into  a  central  or  deep 


Torculur 
Herophili. 

Lateral 
sinus. 

Occipital 
sinus. 


Jugular  vein 


Fig.  47. — Diagram  of  the  venous  sinuses  of  the  brain. 

set,  which  unite  with  the  veins  of  Galen  entering  the  straight 
sinus,  and  a  superficial  set  for  the  cortex,  the  superior  of  which 
enter  the  superior  longitudinal  sinus,  the  inferior  being  re- 
ceived by  the  cavernous,  petrosal,  and  other  sinuses.  The 
straight  sinus  receives  the  inferior  longitudinal  sinus,  and 
unites  with  the  occipital  sinus  and  superior  longitudinal 
sinus,  at  the  Torcular  Herophili,  which  empties  into  each 
lateral  sinus,  and  thus  into  the  internal  jugular  veins. 

The  Cerebellum  derives  its  arterial  supply  from  the  verte- 
bral and  basilar  arteries,  and  its  veins  enter  the  straight, 
petrosal,  and  other  sinuses. 

The     blood    conditions   in    the   insane   have   been  closely 


THE   PATHOLOGY   OF   INSANITY  249 

investigated,  but  beyond  those  associated  with  Diabetes,  Gout, 
Syphihs,  and  other  somatic  disorders,  there  are  not  any  pro- 
nounced changes  to  be  noted.  Ansemia  is  certainly  present  in 
many  cases ;  according  to  Lewis  Bruce,  leucocytosis  exists  in 
many  insanities,  especially  in  the  Confusional  types,  the  white 
blood  cells,  70  %  of  which  consist  of  polymorpho-nuclears,  being 
increased  from  10,000  to  50,000  per  c.mm.  Nothing  certain 
is  known  as  to  the  nature  of  the  different  forms  of  hypothetical 
auto-toxsemia,  whether  from  altered  internal  secretions  of  the 
ductless  glands  or  from  toxins,  the  result  of  organisms  in  the 
alimentary  tract,  which  the  protective  forces  of  the  body 
are  apparently  unable  to  deal  with.  It  may  be  said  that 
micro-organisms  in  the  blood  are  generally  conspicuous  by 
their  absence  in  insanity.  Opsonic  work,  moreover,  has  so 
far  not  thrown  any  fresh  light  on  blood  conditions  in  the 
insane.  Clinically  the  general  blood  pressure  is  frequently 
raised  in  cases  of  depression,  and  it  is  sometimes  lower  than 
normal  in  excited  patients,  whatever  the  explanation  may  be. 

The  cerebral  circulation  is  under  vasomotor  influence  that 
is  not  fully  understood.  It  is  probable  that  vascular  changes 
are  more  often  secondary  to  nervous  molecular  changes  and 
are  not  primary  factors.  It  would  appear  that  the  blood 
supply  of  localised  areas  of  the  cortex  may  be  temporarily 
inhibited.  In  strong  emotions,  vascular  appearances  in  the 
body  are  generally  accompanied  by  corresponding  vascular 
changes  in  the  brain.  Cortical  activity  is  associated  with 
increased  flow  of  blood  through  the  brain,  whilst  during  sleep 
the  cortex  is  undoubtedly  anaemic. 

In  many  cases  of  Melancholia  and  Stupor,  the  cortex 
is  probably  anaemic,  with  a  sluggish  circulation  and  venous 
congestion,  whilst  in  Mania,  especially  in  the  acute  stage,  and 
in  Delirium,  hypereemia  is  the  rule.  It  has  been  demonstrated 
experimentally  that  ansemia  of  the  brain  can  cause  delirium  as 
well  as  unconsciousness,  so  also  does  chronic  congestion  of 
the  brain,  as  in  heart  and  lung  disease.  It  would  appear, 
therefore,  that  whatever  alteration  of  the  blood-flow  occurs, 
the  quality  of  the  blood  must  be  taken  into  account ;  and  that 
the  metabolism  and  proper  oxygenation  of  the  neurons,  on 
which  the  healthy  nutrition  of  the  cortex  depends,  result  from 
a  combination  of  factors. 


250  MENTAL   DISEASES 

Some  of  the  congestive  seizures  of  General  Paralysis  are 
due  to  circulatory  derangements,  which  are  restored  by  means 
of  collateral  anastomoses  in  the  cortex.  Similarly  the  transi- 
tory Aphasia  and  Amnesia  sometimes  observed  in  the  insane 
may  be  due  to  localised  circulatory  influences.  Blockage  of 
capillaries,  and  minute  haemorrhages  are  frequently  seen  in 
sections  taken  from  persons  dying  insane ;  in  Idiocy  and 
Dementia  the  capillaries  often  look  like  fine  bands,  and  are 
evidently  disused.  In  General  Paralysis  there  is  marked 
proliferation  of  the  endothelium  of  capillaries,  and  perivascular 
infiltration  with  lymphocytes  and  plasma  cells.  There  is  also 
considerable  new  formation  of  capillaries  in  the  cortex  {vide 
Figs.  40  and  48),  and  also  in  the  pia  mater,  where  they  should 
not  exist  at  all.  These  are  prone  to  rupture  in  the  pia 
arachnoid,  and  lead  to  organised  blood  clots.  Thromboses 
and  emboli  are  occasionally  seen  in  the  small  arterioles.  These 
are  often  associated  with  miliary  aneurysms  which  rupture, 
producing  haemorrhages. 

The  coats  of  the  cerebral  arteries  are  frequently  diseased  in 
Arteriopathic  Dementia,  Senility,  and  in  chronic  Alcoholism. 
The  vessels  become  tortuous  and  atheromatous  (endarteritis 
deformans).  The  degeneration  of  the  internal  coat  may  be 
fatty,  hyaline,  or  fibroid,  and  calcification  is  not  uncommon. 
The  muscular  coat  also  shows  granular  changes  and  colloidal 
degeneration,  and  the  external  coat  is  thickened  (periarteritis.) 
In  General  Paralysis  and  Syphilitic  brain  disease  the  internal 
coat  is  thickened,  and  the  lumen  of  the  artery  is  contracted 
(endarteritis  obliterans). 

The  venous  sinuses  are  occasionally  subject  to  thrombosis 
from  septic  disorders  of  the  ear,  nose,  or  throat,  and  of  the 
cranium  and  scalp,  with  which  latter  the  sinuses  are  in 
communication  by  veins  piercing  the  bone. 

The  Membranes  of  the  Brain. — The  pia  arachnoid,  for 
the  most  part,  may  be  described  as  one  membrane.  It  covers 
the  surface  of  the  cortex,  and  lines  the  ventricles,  forming 
folds  for  the  Choroid  plexus  and  velum  interpositum.  The 
pia  itself  dips  deeper  into  the  sulci  of  the  cortex  than  does 
the  arachnoid,  which  is  its  endothelial  lining.  Between  it 
and  the  dura  is  the  arachnoid  space.     The  two  layers  bounding 


3      ^  a^- «?  ^®' 


«ea*A  «  •   , 


& 


#$> 


<;b 


A-n-K. 


Fig.  48. — Perivascular  infiltration.     (Nissl  X  300.) 


Plasma  cell. 


Endothelial  cell. 


Nerve  i  \«  i"^  a  /  ^  ,|w 

ce„.  -^_    „^      XHa?-*-  X  /^ 


r- 


r    i 


A   ^\'K 


Fig.  -±9. — Proliferating  capillaries ;  also  plasma  and  endothelial  cells. 
(Nissl  X  300.) 

[To  face  paye  -50 


THE   PATHOLOGY   OF   INSANITY  251 

the  space,  however,  are  closely  approximated,  excepting  at 
the  lacunae  between  the  sulci  and  certain  cisternee,  especially 
at  the  base,  where  the  cerebro -spinal  fluid  collects.  The  pia 
is  composed  of  delicate  areolar  tissue  containing  the  arterioles 
and  venules,  with  their  perivascular  lymphatic  channels, 
which  perforate  the  cortex  vertically  and  minister  to  the  nutri- 
tion of  the  cortex.  Normally,  it  should  be  fairly  easily  separ- 
ated from  the  cortex.  In  chronic  insanity  the  pia  arachnoid 
becomes  milky  and  opaque  from  blockage  of  the  lymph  spaces, 
and  it  is  thickened  and  adheres  to  the  brain  tissue  in  parts, 
from  neuroglial  overgrowth.  It  loosens  again  later  from 
fatty  liquefaction  due  to  localised  softenings,  and  sometimes 
from  post-mortem  changes.  On  stripping  the  pia  arachnoid 
from  the  cortex  in  an  advanced  case  of  General  Paralysis, 
the  worm-eaten  appearance  (decortication),  already  mentioned, 
on  the  surface  of  the  brain  is  due  to  the  same  process.  Micro- 
scopically the  membrane  is  also  infiltrated  with  Ij^mphocytes 
and  plasma  cells.  In  this  disease,  as  has  also  been  mentioned 
before,  the  ependyma  of  the  ventricles — especialty  the  fourth — 
is  granular  or  frosted  from  hyperplasia  of  the  epithelium  and 
prohferation  of  the  subjacent  neuroglia  (vide  Fig.  44,  facing 
p.  244).  This  appearance  is  often  also  evident  on  the  choroid 
plexus  and  velum  interpositum,  and  is  probably  due  to  the 
irritation  of  toxic  products  in  the  cerebro -spinal  fluid.  A  sub- 
dural false  membrane  is  present  on  rare  occasions  :  this  is 
due  to  fibrous  changes  in  an  old  blood-clot,  either  from 
rupture  of  pial  vessels,  or  from  a  hsematoma  of  the  dura 
mater  effusing  into  the  arachnoid  cavity,  producing  the 
so-called  pachjonengitis  hsemorrhagica. 

The  Dura  Mater  is  a  more  fibrous  membrane,  which  contains 
the  venous  sinuses  between  its  two  layers.  It  forms  the  in- 
ternal periosteum  for  the  Cranium,  and  is  usually  adherent 
to  the  bone  at  the  base  of  the  skull,  but  is  normally  somewhat 
free  at  the  vertex.  It,  however,  is  not  infrequently  attached 
in  the  frontal  region  and  along  the  sagittal  suture,  as  a  result 
of  deposition  of  new  bone,  which  is  sometimes  accompanied  by 
infiammatory  changes  (ossifying  pachjTneningitis).  This  ossifi- 
cation, or  calcification,  is  often  seen  in  old  Dements  and  in 
Senility,  independently  of  insanity,  and,  indeed,  it  affects  the 
dural   processes   sometimes.     These   processes   form   the   falx 


252  MENTAL   DISEASES 

cerebri  and  cerebelli  with  the  tentorium  cerebelli  intervening. 
The  internal  IsLjev  is  smooth,  with  an  endothehal  hning,  and 
between  the  fibrous  meshes  of  the  outer  layer  are  blood- 
vessels mth  perivascular  lymph  channels,  and  lymphatic 
spaces  which  become  choked  in  General  Paralysis.  But  rarely 
is  the  dura  mater  ever  adherent  to  the  pia  arachnoid.  In  both 
General  Paratysis  and  Senility  it  is  commonly  thickened  and 
undul}^  opaque  as  the  degenerative  changes  advance,  and 
rarel}^  does  it  become  thinner  than  normal.  As  has  already 
been  mentioned,  it  is  sometimes  the  seat  of  haemorrhage — 
pachymeningitis  haemorrhagica . 

The  Pacchionian  Bodies,  which  are  present  on  the  outer 
surface  of  the  dura  mater,  and  sometimes  groove  the  skull,  lie 
mostly  along  the  superior  longitudinal  sinus,  and  project 
therein.  They  are  in  reality  arachnoid  processes,  which 
proliferate  and  push  the  thinned  dura  before  them.  They 
increase  in  size  mth  age,  but  have  no  particular  significance 
in  insanity. 

The  Pituitary  Oland  is  not  as  a  rule  structurally  affected  in 
insanity.  Like  the  thyroid,  supra-renal,  and  sexual  glands,  it 
exerts  considerable  influence  on  the  nutrition  of  the  nervous 
system  and  body  generally.  Its  internal  secretion,  besides 
entering  the  blood,  probably  also  adds  ingredients  to  the 
cerebro -spinal  fluid  through  the  third  ventricle.  Situate  in 
the  Sella  Turcica  its  anterior  epithelial  part  is  enlarged  in 
Giants  and  Acromegalics.  Its  posterior  part  is  mostly 
neuroglial,  and  an  extract  thereof  markedly  increases  renal 
and  lactational  activitj^,  besides  raising  the  general  blood 
pressure. 

The  Pineal  Body  often  contains  earthy  salts  (brain  sand). 
It  has  no  known  function,  and  is  probably  the  remnant  of  an 
ancestral  eye. 

The  Cranium. — The  shape  of  the  skull  is  largely,  if  not 
entirely  determined  hj  the  configuration  and  size  of  the  brain. 
There  is  no  evidence  to  favour  the  view  that  premature 
synostosis  of  the  skull  ever  occurs,  preventing  brain  growth. 
In  some  cases  the  frontal  suture  persists.  In  the  insane  the 
skull  undoubtedly  deviates  from  the  average  normal  standard 
more  than  in  the  sane  population,  but  not  as  often  as  is 
generally  thought.     Some  skulls  are  manifestly  asymmetrical 


THE   PATHOLOGY   OF  INSANITY 


253 


and  degenerate  in  formation,  mth  recession  of  forehead  and 
prominence  of  maxillae  (prognathism),  a  flattened  nose,  and 
an  acute  facial  angle  (^.  e.  less  than  75°  as  measured  from  the 
the  central  incisors  to  the  forehead  and  ear).  Not  much  differ- 
ence between  the  sane  and  the  insane  is  to  be  noted  in  the 
size  and  capacity  of  the  skull,  which  depend  largely  on  the 
height  of  the  individual,  and  on  racial  and  other  characteristics. 
The  circumference  of  the  head  of  the  newborn  child  is  usually 
about  13  or  14  ins.  The  average  normal  circumference  in 
adults  should  be  22|  ins.,  the  greatest  length  and  breadth  7|, 
and  6^  ins.  respective^,  as  measured  by  callipers.  The 
"  cephalic  index  "  is  calculated 
by  multipljdng  the  breadth  by 
100  and  dividing  hj  the  length  ; 
it  varies  between  70  and  90. 
Some  Microcephalic  idiots  have 
very  small  skulls — below  17  ins. 
in  circumference  —  whilst  in 
Hydrocephalus,  and  Hypertro- 
phic idiocy  the  skull  may  be 
enormous,  from  25  to  40  ins. 
in  circumference.  As  to  its 
bony  structure,  about  50  %  are 
thickened  (osteo-sclerosis)  with 
very  little  diploe,  and  under 
2  %  are  tliinner   than   normal 

(osteo-porosis).  The  former  is  usual  in  chronic  Epileptics  from 
active  nutritional  changes,  and  the  latter  occurs  in  H3^dro- 
cephalus  and  in  some  old  Dements.  Bony  outgrowths  are  to 
be  seen  occasionally^  in  chronic  Dements  and  in  General 
Paralji^ics.  The  teeth  in  some  of  the  insane  are  prone  to 
project  unduly,  and  are  frequently  misplaced,  irregular,  and 
carious. 

The  Palate  is  frequently  deformed,  unduly  arched,  or 
V-shaped  in  insanity,  especially  in  that  of  degenerate  origin. 
It  is  due  to  defective  growth  of  the  superior  maxilla  and  palate 
bones. 


Fig.  50. — The  V-shaped  palate. 


The    Ears    are    also    sometimes  abnormally    implanted, 
malformed,    asymmetrical,    too    small    or,    more    generally. 


254 


MENTAL   DISEASES 


they  are  enlarged,  and.  they  project  outwards.  There  is 
frequently  prominence  of  the  Darwinian  tubercle,  the  lobule 
being  adherent  or  absent,  and  many  other  anomalies  of  the 
ears  may  exist. 

Stigmata  of  degeneracy  sometimes  are  found  in  other  regions 
of  the  body,  e.  g.  genital  anomalies,  femininism,  masculinism, 
hairiness,  hernise,  spinal  deformity,  club-foot,  spina  bifida, 
polydactylism,  etc.  Here  it  may  be  mentioned  that  many 
sane  persons  exhibit  an  occasional  stigma  of  some  kind, 
and  that  it  is  only  when  many  of  these  physical  defects  are 
observed  in  the  same  individual  that  degeneration  can  really 
be  said  to  exist.     Moreover,  in  such  a  case,  they  are  usually 


Fig.  51. — Abnormalities  of  the  ear. 
(a)  Adherent  lobule  ;   (6)  Darwinian  tubercle. 

accompanied  by  psychic  stigmata.  It  should  be  noted  also, 
that  many  varieties  of  insanity  are  entirely  free  from  degenera- 
tion at  all. 

HsBmatoma  Auris,  Othsematoma,  or  the  so-called  Insane 
Ear,  occasionally  occurs  in  General  Paralytics,  Epileptics,  and 
restless  cases  generally,  and  is  always  due  to  injury  of  some  kind. 
It  has  not  such  prognostic  value  as  was  once  supposed.  It 
results  from  defective  nutritional  changes  in  the  ear  cartilage, 
which  loses  its  elastic  fibres,  and  becomes  cystic  and  hsemor- 
rhagic.  The  blood  coagulates,  and  finally  fibrotic  contraction 
ensues,  leading  to  disfigurement  of  the  ear  if  untreated. 
The  hsematoma  occurs  also  in  some  normal  individuals 
especially  in  footballers  and  boxers. 


THE   PATHOLOGY   OF   INSANITY 


255 


Trophic  Disturbances. — Finall}^,  disease  of  the  cerebral 
cortex  reflects  itself  in  general  failure  of  the  metabolism  and 
nutrition  of  the  body.  Loss  of  weight  is  frequent  in  acute 
insanity,  and  although  in  the  mid-stage  of  General  Paralysis 


/*"' 


"^^ 


Fig.  52. — Hgematoma  auris;   (a)  cystic;   (6)  fibrotic. 

and  in  quiescent  Dementia,  patients  are  prone  to  become  fat, 
most  progressive  cases  tend  to  emaciation.  Bed-sores  are  liable 
to  arise  from  shght  pressure,  the  skin  may  become  glossy,  the 
nails  grooved,  and  the  hair  brittle,  while  trophic  changes  may 
be  observed  in  the  viscera. 


CHAPTER   XXI 
THE    ELEMENTS    OF    PROGNOSIS 

To  prophesy  the  course  and  termination  of  mental  disorder 
in  a  given  case  is  often  the  hardest  task  of  the  physician. 
According  to  the  extent  of  his  experience  \^dll  he  be  able  to  fore- 
shadow the  future  of  his  patient,  and  to  be  more  or  less  correct 
in  his  prognosis.  Upon  his  opinion  much  frequently  depends, 
for  financial  and  family  arrangements  have  to  be  considered  in 
Mental  diseases  more  than  in  other  departments  of  Medicine. 
Therefore,  on  the  accuracy  of  prognosis,  anxious  thought  has 
to  be  spent,  as  the  matter  entails  no  little  responsibility.  At 
the  same  time,  to  be  too  guarded  savours  of  ignorance,  and 
there  are  certain  indications  which  enable  an  opinion  to  be 
formed  with  some  amount  of  justification. 

In  some  instances  a  prognosis  can  be  given  mthout  much 
difficulty,  whilst  in  others  physicians  of  ecjual  experience  will 
differ.  Especially  is  the  prognosis  dubious  when  the  type  of  in- 
sanity is  ill-defined,  or  is  composed  of  more  than  one  psychosis, 
or  where  the  etiology  is  complex  and  the  capacity  and  quahty 
of  the  innate  nervous  constitution  more  doubtful  than  usual. 
Considerable  assistance  may  be  derived  from  an  authentic 
history  of  the  patient.  Thereb}^  can  be  learnt  what  his 
previous  tendencies  have  been,  and  to  what  use  or  abuse  he  has 
subjected  his  natural  powers.  Information  should  be  elicited 
whether  he  was  regarded  as  an  average  normal  person,  or 
whether  he  was  nervous,  excitable,  shy,  apathetic,  or  depressed  ; 
or  again,  whether  he  previously  exhibited  some  other  morbid 
mental  trait  upon  which  the  mental  disorder  has  been 
engrafted.  Usually,  the  more  normal  a  patient  was  before  a 
breakdown,  the  better  are  the  chances  of  his  recovery. 

Although  there  are  conditions  of  transient  excitement  and 
depression  lasting  from  a  few  hours  to  a  few  days,  which  are 

256 


THE   ELEMENTS   OF   PROGNOSIS  257 

exaggerations  of  the  rhythm  common  to  most  individuals, 
the  majority  of  mental  diseases  run  a  course  consisting  of  weeks 
or  months,  before  recovery  can  be  expected ;  and  thus  they 
contrast  with  most  other  diseases  in  their  longer  average 
duration.  Mental  diseases,  accordingly,  are  naturally  looked 
upon  as  a  greater  calamity,  involving  as  they  do  considerable 
expense,  owing  to  the  necessity  of  special  nursing  and  change 
from  home,  which  expense  not  infrequently  pauperises  the 
patient  of  spare  means.  The  friends  of  a  patient  are  naturally 
anxious  to  have  a  forecast  of  the  case.  Will  he  recover,  and  if 
so,  in  what  space  of  time  ?  Will  the  recovery  be  complete,  or 
will  his  mind  be  in  any  way  affected,  so  that  he  will  be  different 
from  what  he  was  before  ?  What  are  the  chances  of  a  relapse 
or  of  a  recurrence  ?  In  a  severe  case,  is  there  any  likelihood 
of  a  fatal  issue,  from  exhaustion  or  complications  ?  If  the 
patient  is  an  early  General  Paralytic,  how  long  will  he  live,  and 
is  a  remission  to  be  expectei  ?  These,  and  sundry  other 
questions,  the  relatives  of  patients  are  prone  to  ask. 

In  order  to  prognose  with  any  pretence  to  certitude,  a 
correct  diagnosis  must  be  made.  This,  however,  is  not  always 
an  easy  matter,  in  the  absence  of  a  knowledge  of  the  patient's 
temperament  and  of  the  details  of  his  past  history.  Remarks 
have  already  been  made  as  to  prognosis  under  the  different 
psychoses,  and  it  is  proposed  now  to  give  a  general  outline,  by 
way  of  recapitulation. 

As  regards  sex,  the  prognostication  is  rather  better  in 
females  than  in  males.  With  reference  to  age.,  the  younger  the 
patient,  the  better  are  the  recuperative  forces  and  the  chances 
of  recovery,  and  the  shorter  is  the  attack  likely  to  be.  It 
must,  however,  be  borne  in  mind  that  insanity  in  early  life 
indicates  a  serious  want  of  nervous  stamina,  for  it  is  unusual 
for  an  adolescent  patient  to  have  been  subject  to  much  of  the 
external  stress  of  life.  Many  of  these  cases  are  instances  of 
Dementia  Preecox  in  which  the  ultimate  issue  is  unfavourable  : 
others  are  failures  of  evolution  in  which  but  little  improvement 
is  to  be  expected,  and  which  are  manifested  by  the  various 
grades  of  Imbecility  and  Feeble-mindedness,  and  in  its  marked 
degree,  by  such  mental  impairment  from  birth  as  to  be  classed 
as  Idiocy.  The  determining  causes  in  every  case  should  be 
elucidated  as  far  as  possible.     To  what  extent  does  heredity 


258  MENTAL   DISEASES 

influence  the  case  ?  What  kind  of  family  stock  does  the 
patient  spring  from  ?  It  has  been  said  that  where  instability  is 
marked,  the  molecular  changes  in  brain  constitution,  culminat- 
ing in  an  attack  of  insanity,  are  just  as  likely  to  revert  back 
to  the  normal,  so  that,  contrary  to  popular  opinion,  an  insane 
heredity  does  not  necessarily  prejudice  recovery  from  the  attack 
in  question,  but  the  chances  of  recurrence  are  nevertheless 
more  probable.  This  is  well  exemplified  in  Maniacal-Depressive 
insanity;  and  it  applies  similarly  to  a  family  history  of 
Alcoholism,  Epilepsy  and  Neuroses,  although  in  less  degree. 
The  prognosis  is  unfavourable  in  cases  derived  either  from 
a  stock  of  low  intelligence,  or  from  one  in  which  eccentricity  is 
prominent,  as  in  these  the  stigmata  of  degeneration  are  likely 
to  be  found. 

With  regard  to  cases  that  are  attributed  to  sudden  causes 
such  as  emotional  Shocks  and  Frights,  it  must  be  pointed  out 
that  insanity  cannot  develop  in  a  moment,  except  in  pre- 
disposed persons.  These  cases  invariably  have  shown  indica- 
tions of  mental  instability  beforehand  which  have  frequently 
been  unnoticed.  The  more  acute  the  onset  the  more  favourable 
is  the  prognosis,  and  the  possibility  of  a  sudden  recovery. 

Cases  in  which  the  chief  factors  in  the  etiology  are  definite 
and  removable,  as  a  rule  do  well,  such  as  Puerperal  cases, 
Confusional  and  Stuporous  cases,  especially  if  associated  with 
anaemia,  constipation  or  other  somatic  affections.  Likewise  is 
the  course  hopeful  in  Alcoholic  cases,  provided  the  poison  is  not 
too  long  continued,  but  it  must  be  borne  in  mind  that  they 
have  an  overpowering  tendency  to  relapse,  especially  in 
females.  Cases  occurring  in  connexion  with  the  Menopause 
are  on  the  whole  satisfactory ;  improvement  may,  however, 
be  delayed,  perhaps  for  two  or  three  years.  An  acute  attack 
of  insanity,  as  a  rule,  has  a  better  prognosis  than  a  slowly 
developing  mental  derangement.  Although  mental  depression 
associated  with,  or  dependent  as  it  so  often  is  on,  visceral 
and  other  disturbances  is  eminently  curable,  yet  when  it  passes 
the  border-line  of  sanity,  the  prognosis  of  Melancholia  in 
asylum  cases,  which  of  course  are  usually  the  woTst,  is  not 
quite  so  good  as  that  of  Mania.  Moreover,  its  course  is  apt 
to  be  longer,  and  when  associated  with  Hypochondriacal 
delusions,  the  prognosis  as  regards  recovery  is  less  certain, 


THE   ELEMENTS   OF   PROGNOSIS  259 

and  the  risk  of  suicide  has  always  to  be  encountered.  The 
subsidence  of  emotional  symptoms  and  the  advent  of  aural 
hallucinations  invariably  portend  chronicity.  Cases  of  Mania 
usually  get  well  within  six  months,  but  they  seldom  recover  if 
they  last  two  or  more  years.  Cases  of  Melancholia,  however, 
have  been  known  to  be  discharged  cured,  after  ten  years' 
duration.  These  two  phases  of  Maniacal-Depressive  disorder 
sometimes  kill  the  patient  by  sheer  exhaustion,  in  Mania  more 
often  than  in  Melancholia,  and  this  occurs  also  in  Acute 
Confusional  insanity.  Acute  Delirious  Mania  is  a  peculiarly 
fatal  malady,  and  when  patients  survive,  it  almost  always 
leaves  permanent  mental  weakness.  The  more  severe  Puerperal 
cases  resemble  it  in  this  respect. 

General  Paralysis  is  still  a  hopeless  disease,  the  average 
duration  of  which  is  about  two  to  three  years.  It  is  true  that 
some  patients  appear  to  get  well,  the  disease  being  arrested,  so 
that  remissions  occur ;  these  are  seldom  long,  they  take  place 
mostly  in  the  expansive  form,  sometimes  in  the  depressed 
type,  but  practically  never  in  the  demented  form  of  the  disease. 
The  physician  must  be  sure  of  his  diagnosis  before  giving  his 
opinion,  for  some  cases  resemble  Alcoholic  insanity.  Cerebral 
Syphilis,  and  other  conditions,  and  early  cases  have  been 
mistaken  for  Neurasthenia. 

The  insanity  of  Epilepsy  is  of  bad  prognosis.  Patients 
recover  from  attacks  of  epileptic  excitement,  but  the  tendency 
to  recurrence  and  Denfentia  is  pronounced,  especially  if  the  fits 
are  frequent  and  are  also  of  the  petit  mal  type. 

The  insanity  from  Gross  Brain  lesions,  or  Traumatism,  is 
always  unfavourable  as  regards  recovery,  as  is  also  that 
associated  with  Phthisis,  Chronic  Renal,  or  Arteriopathic 
disease. 

Of  the  Senile  psychoses,  attacks  of  simple  Mania  and  Melan- 
cholia sometimes  yield  to  treatment  and  end  in  recovery,  but 
the  disorders  are  usually  progressive,  and  the  patient  becomes 
demented,  and  seldom  lives  long.  Dementia  is  almost  synony- 
mous with  incurability,  although  some  cases  of  Dementia 
Prsecox  do  recover.  Dementia  is  due  to  organic  destruction 
of  brain  tissue,  which  is  past  repair ;  it  should  be  differentiated 
from  Stupor,  which  is  dependent  on  functional  dissociation, 
and  when  not  prolonged  is  eminently  curable.     In  Congenital 


260  MENTAL   DISEASES 

cases  little  can  be  done  from  a  curative  point  of  view,  but 
Imbeciles  and  Feeble-minded  persons  improve  under  discipline 
and  routine.  The  severer  types  of  Idiocy  rarely  reach  maturity  : 
in  fact,  most  Idiots  are  short-lived. 

Prognosis  in  insanity  is  in  great  measure  dependent  on  the 
duration  of  the  disease  prior  to  the  patient's  coming  for  treaty 
ment.  The  early  signs  of  mental  disorder  in  a  poor  person 
scarcely  receive  attention.  He  has  no  opportunity  for  rest 
till  he  loses  his  employment,  and  when  the  disorder  is  fully 
developed  the  relieving  officer  has  to  be  called  in  for  assist- 
ance. With  the  person  of  means,  on  the  other  hand,  the 
relatives  are  unwilling  to  face  the  facts,  and  they  try  to  avoid 
the  issue  through  makeshifts  of  various  kinds  by  which  the 
best  attention  and  a  good  prognosis  become  jeopardised. 

There  are  certain  indications  in  the  progress  of  a  case  which 
are  of  good  and  of  bad  import,  to  which  reference  must  be  made. 
If  a  patient  gains  weight  and  shows  bodily  improvement,  and 
yet  the  abnormal  mental  condition  remains  the  same,  the  out- 
look is  an  unfavourable  one.  A  person  on  the  road  to  Dementia 
frequently  becomes  fat.  A  gradual  improvement  in  both  the 
physical  and  mental  states  is  more  conducive  to  a  durable 
recovery  than  sudden  and  periodic  lucid  intervals  during 
the  course  of  the  disorder.  In  females  between  the  ages  of 
about  fifteen  and  forty-five  the  menses  in  mental  disorders 
are  frequently  affected,  in  acute  states  there  may  be  a  cessa- 
tion of  the  menstrual  flow,  and  in  patients  who  improve 
there  usually  is  a  return  of  the  natural  periods;  in  chronic 
cases,  however,  the  menses  continue  for  the  most  part  in  an 
irregular  manner. 

The  persistence  of  certain  symptoms  is  unfavourable. 
Thus,  obstinate  refusal  of  food,  necessitating  tube-feeding  over 
a  considerable  period  of  time,  is  of  bad  import,  and  so  is  a 
recurring  suicidal  tendency.  A  delusion  that  is  becoming  fixed 
— which  sometimes  happens  in  Maniacal-Depressive  and  Con- 
fusional  insanities— or  delusions  that  are  systematised  (Para- 
noia), and  the  development  of  persistent  hallucinations — 
especially  of  hearing — in  any  variety  of  insanity,  are  all  of 
bad  prognostic  import.  Other  unfavourable  symptoms  are  : 
vacancy  and  fixity  of  expression,  apathy  or  aversion  towards 
relatives,  marked  loss   of  memory — if  persistent — neglect  of 


THE   ELEMENTS   OF   PROGNOSIS  261 

personal  appearance  and  attire,  the  growth  of  hair  on  the 
face  in  females,  wet  and  dirty  habits,  repeated  masturbation, 
picking  of  skin,  nail-biting,  piilHng  out  of  hair,  general  de- 
structiveness,  collecting  rubbish,  etc.,  stereotyped  movements 
and  mannerisms.  Marked  periodicity,  as  in  Alternating  insanity, 
is  usually  of  bad  omen  as  regards  recovery,  although  differing 
from  Intermittent  cases  in  which  each  succeeding  attack  tends 
a  further  step  towards  Dementia.  Patients  with  a  suspicious  or 
jealous  temperament,  those  with  fervent  religious  or  erotic  emo- 
tions, and  those  subject  to  impulses,  obsessions,  or  morbid  fears 
and  doubts  (Psychasthenia)  must  always  be  given  a  guarded 
prognosis.  This  applies  equally  to  patients  of  the  Neuras- 
thenic type,  but  in  Hysterical  affections  the  issue  is  more 
hopeful.  Delusional  cases,  as  a  rule,  have  a  better  outlook, 
if  the  patients  originally  possessed  good  mental  powers,  and  if 
the  delusions  change  from  time  to  time.  Bad  physical  health,  as 
indicated  by  loss  of  weight,  a  sallow  complexion,  a  rapid  and 
feeble  pulse,  a  rise  of  temperature,  or  a  dry  tongue  with'  sordes 
on  the  lips,  whether  induced  by  the  mental  disorder,  by  com- 
plications, or  by  pre-existing  bodily  disease,  always  renders 
the  prognosis  grave. 

Variation  in  symptoms  is  a  hopeful  sign,  as  is  also  a  return 
to  cleanliness  of  habits,  a  gradual  interest  in  surroundings, 
a  desire  for  former  pursuits,  and  a  recognition  by  the  patient 
of  the  stages  of  his  disorder  (insight).  About  the  most  hope- 
jul  cases,  next  to  mild  Melancholiacs  that  scarcely  require 
certification,  are  attacks  of  Acute  Mania  in  young  people, 
and  of  Anergic  Stupor,  Recent  Melancholiacs,  Puerperal  cases. 
Alcoholic  and  other  Confusional  insanities. 


CHAPTER   XXII 
THE  LEGAL  RELATIONS  OF  INSANITY  AND  MENTAL  DEFICIENCY 

From  the  medical  point  of  view,  when  a  person  is  alleged  to 
be  insane  or  mentally  deficient,  he  is  assumed  to  be  suffering 
from  some  form  of  brain  disorder  (or  defect),  functional  or 
otherwise.  Such  disorder  manifests  itself  in  aberration  of 
conduct,  which  the  physician  has  to  consider,  together  with 
other  symptoms,  in  the  diagnosis  of  the  condition. 

The  legal  aspect  of  the  case  is  somewhat  different.  It  is 
concerned  only  with  the  conduct  or  action  of  the  individual  in 
question,  and  with  his  verbal  and  written  statements. 

Is  he  able  to  look  after  himself  and  his  affairs  ?  Is  it  safe 
to  leave  him  to  his  own  devices  ?  Is  he  competent  to  transact 
business  ?  Is  it  right  to  interfere  with  his  liberty  ?  Has  he 
sufficient  mental  capacity  to  make  a  valid  will  ?  Should  a 
contract  he  is  making  be  regarded  as  binding  ?  Is  he  re- 
sponsible for  his  actions  if,  as  alleged,  he  has  committed  a 
crime,  and  did  he  know  what  he  was  doing  and  could  he  help 
it  ?  Is  he  a  menace  to  himself  or  to  others  either  as  regards 
person  or  property  ?  The  legal  standard  of  insanity  not  being 
the  same  in  all  these  circumstances,  these  questions  range 
themselves  under  four  main  headings,  viz.  : — 

(1)  Certification  for  care  and  treatment, 

(2)  Testamentary  capacity, 

(3)  Civil  liability, 

(4)  Criminal  responsibility, 

1.  GertijEication  for   Care   and   Treatment 

The  procedure  for  England  and  Wales  will  be  considered 

262 


THE   LEGAL   RELATIONS    OF   INSANITY       263 

first.    This  includes  the  Lunacy  Act,  1890  (and  its  amendments), 
and  the  Mental  Deficiency  Act,  1913. 

The  Lunacy  Act. — Not  every  person  exhibiting  disorder  of 
mind  is  to  be  regarded,  in  the  legal  sense,  as  a  case  of  insanity, 
and  it  is  not  every  case  of  insanity  that  requires  detention  for 
treatment.  Certification  is,  however,  necessary  in  the  majority 
of  instances  in  the  interests  of  the  patient,  and  to  comply  with 
the  lunacy  law  as  at  present  constituted.  There  is  unfortun- 
ately still  a  stigma  attaching  to  certification  which  is  quite 
unwarrantable,  so  that  it  is  urged  that  temporary  notification 
should  be  permissible,  by  amendment  of  lunacy  legislation, 
for  transient  curable  cases  without  the  trammels  of  the  existing 
formalities. 

An  insane  patient  requires  protection  of  some  kind  to  prevent 
hisfalling  an  easy  victim  to  unprincipled  persons  ;  his  misfortune, 
moreover,  is  apt  to  involve  him  in  loss  of  money  and  property, 
and  he  is  sometimes  a  possible  source  of  danger  to  other 
people.  Certification  may  be  dispensed  with  in  a  patient, 
with  ample  means,  if  he  can  be  managed  in  his  own  home 
without  any  form  of  restraint  or  loss  of  liberty.  To  promote 
recovery,  however,  it  is  generally  necessary  to  remove  a 
patient  elsewhere,  and  if  certifiably  insane  the  requisite  docu- 
ments must  be  drawn  up.  A  doctor  or  layman  who  receives 
such  a  case  into  his  house  for  payment  without  these  docu- 
ments is  liable  to  a  prosecution  by  the  Commissioners  for  non- 
compliance with  the  law.  A  conviction  under  Sec.  315  of  the 
Lunacy  Act,  1890,  renders  the  person  liable  to  a  penalty  not 
exceeding  £50.  Under  the  common  law  it  is  true  that  evanes- 
cent cases  of  Delirium  Tremens  can  be  restrained  from  doing 
themselves  and  others  harm,  but  even  then  it  is  wise  for  the 
medical  attendant  to  obtain  a  letter  of  indemnity  from  the 
relatives,  in  case  of  subsequent  proceedings  by  the  patient. 
A  writ  of  habeas  corpus  can  be  taken  out  by  any  one  in  a  case 
of  illegal  detention,  and  the  person,  when  free,  can  claim 
damages  for  false  imprisonment.  Sec.  330  enacts  that  nobody 
shall  be  liable  to  any  proceedings  in  pursuance  of  the  Act, 
provided  good  faith  and  reasonable  care  have  been  shown. 
Certifiers  are,  therefore,  to  a  great  extent  protected  from 
malicious  prosecutions ;  proceedings  can  generally  be  stayed 
on    application    to    the    High    Court,    and    they   can    only 


264  MENTAL   DISEASES 

be  taken  by  the  patient  within  twelve  months  of  his 
discharge. 

The  procedure  for  legalising  the  treatment  of  an  insane 
person  differs  according  to  whether  he  is  regarded  as  a  pauper 
or  a  private  patient.  An  attack  of  insanity  entailing,  as  it 
usually  does,  loss  of  employment  and  considerable  expense, 
must  nearly  always  pauperise  those  in  the  working  class  of 
life.  Their  means  are  insufficient  to  pay  the  maintenance 
rate  of  a  county  (or  borough)  asylum,  and  the  medical 
certificate  is  generally  obtained  at  the  cost  of  the  rates. 
Although  most  county  asylums  receive  private  patients,  but 
rarely  are  they  admitted  as  such  on  a  petition  or  urgency 
order.  The  patients  are  admitted  as  paupers,  and  if  their 
means  suffice  they  are  transferred  afterwards  to  the  private 
class,  without  further  certification.  This  occurs  in  about  2  % 
of  these  cases.  The  amount  weekly  charged  as  a  rule  is  21s. 
per  week  for  out-county  private  patients,  and  155.  for  in- 
county  ones,  but  the  county  of  London  only  requires  the  bare 
maintenance  cost — about  10s.  6d. — for  a  pauper  patient  to  be 
transferred  to  the  private  class. 

Paup.er  Patients. — In  the  case  of  a  poor  person  whom  a 
medical  practitioner  believes  to  be  insane,  the  usual  course  is 
to  inform  the  local  relieving  officer  (or  overseer),  who  makes  all 
the  necessary  arrangements.  His  address  can  be  ascertained 
at  the  union  for  the  district,  to  which  workhouse  or  infirmary 
the  patient  can  be  forthwith  removed  by  him  (or  by  the  police), 
if  the  case  is  urgent.  This  is  usually  effected  by  what  is  called 
a  "  three-day  order  "  signed  by  the  relieving  officer.  His  duty 
is  within  three  days  to  give  notice  to  a  Justice  having  juris- 
diction, who  calls  in  a  medical  practitioner  to  examine  the 
patient.  If  the  practitioner  signs  a  Medical  Certificate 
specifying  facts,  that  the  patient  is  insane,  and  the  Justice, 
after  seeing  the  patient,  is  satisfied,  he  signs  a  Summary 
Reception  Order  which  is  accompanied  by  a  Statement  of  par- 
ticulars supplied  by  the  relieving  officer.  The  Justice,  if 
unconvinced  of  the  patient's  insanity,  may  adjourn  the  case 
for  any  period  not  exceeding  fourteen  days,  or  he  may  make 
the  order  and  suspend  its  operation  for  not  more  than  fourteen 
days,  during  which  time  the  patient  can  be  detained  in  the 
workhouse,  pending  the  arrangements  made  for  his  reception 
to  an  asylum,  if  still  insane. 


THE   LEGAL   RELATIONS    OF   INSANITY       265 

This  is  the  usual  method  of  deahng  with  a  pauper  patient. 
He  is  either  sent  to  the  county  asylum  on  a  Summary  Reception 
Order,  direct  from  his  abode,  or  more  generally  to  the  work- 
house infirmary  first — by  the  means  previously  mentioned — 
and  then  to  the  asylum.  If  the  relatives  or  friends  wish  to 
undertake  the  charge  of  a  patient  concerning  whom  a  Summary 
Reception  Order  has  been  made,  the  Act  provides  that  they 
can  do  so  on  condition  that  they  satisfy  the  Justice  or  the 
Visitors  of  the  asylum  that  proper  care  will  be  taken  of  him. 
Many  Alcoholic  cases  are  received  in  the  union  workhouses 
or  infirmaries  on  a  three-day  order  of  the  relieving  officer, 
which  is  prolonged  by  a  special  certificate  of  the  union  medical 
officer  for  another  fourteen  days,  during  which  time  the  patient 
often  recovers  and  is  discharged  without  any  further  procedure. 
The  form  of  this  certificate  is  different  from  an  ordinary 
medical  certificate,  and  it  specifies  that  the  accommodation 
in  the  workhouse  must  be  sufficient  for  the  patient's  proper 
care  and  treatment.  For  prolonged  detention  in  the  work- 
house a  second  medical  certificate  in  similar  form  is  requisite, 
as  well  as  an  order  of  a  Justice.  There  are  about  12,000  of 
such  patients  in  workhouses,  besides  about  7,000  in  the  Metro- 
politan District  (or  workhouse)  asylums. 

In  the  case  of  an  insane  person  wandering  at  large,  whether 
a  pauper  or  not,  the  same  procedure  of  a  Summary  Reception 
Order  is  adopted  through  the  relieving  officer  or  the  police. 

Two  Commissioners  have  also  the  power  to  call  in  a  medical 
practitioner,  and  on  his  certificate,  to  order  a  pauper  patient  to 
be  sent  to  an  asylum — this  procedure,  however,  is  very  rare. 

In  criminal  cases  a  patient  is  sent  from  prison  to  an  asylum 
on  an  order  of  the  Home  Secretary,  and  on  the  expiration  of 
his  sentence,  if  still  insane,  he  has  to  be  certified  for  further 
detention. 

Private  Patients. — In  the  case  of  an  alleged  insane  person 
who  is  not  a  pauper  but  is  believed  to  be  neglected  or  cruelly 
treated,  or  is  not  under  proper  care  and  control,  the  police  or 
relieving  officer  should  be  informed.  They  then  notify  a  Justice, 
who  directs  two  medical  practitioners  to  visit  and  examine  that 
person.  If  they  certify  him  to  be  insane,  the  Justice,  if  satis- 
fied, whether  he  sees  him  or  not,  can  sign  a  Summary  Reception 
Order  for  his  admission  to  an  asylum.  Excepting  this  last 
provision  and  when  an  insane  person  is  wandering  at  large,  a 


266  MENTAL   DISEASES 

private  patient  is  usually  placed  under  care  and  treatment 
through  the  intermediation  of  his  relatives  or  friends.  The 
medical  practitioner  in  attendance  has  probably  been  advising 
certification,  and  to  him  generally  falls  the  lot  to  make  the 
arrangements. 

The  necessary  fqrms  can  be  purchased  from  Shaw  &  Sons, 
Fetter  Lane,  E.G.,  or  any  other  law  stationers,  or  if  it  is  pro- 
posed to  send  the  patient  to  a  private  asylum  or  registered 
hospital,  they  can  usually  be  procured  from  the  Medical  Super- 
intendent of  the  Institution,  or  they  can  be  in  handwriting 
throughout.    They  consist  of  : — 

The  Petition  and  Statement. 
Two  Medical  Certificates. 
The  Justice's  Order. 

If  the  case  is  urgent,  requiring  immediate  action,  an  Urgency 
Order  and  Certificate  can  be  utilised  as  a  preliminary. 

All  these  forms  require  the  greatest  care  in  filling  up. 
Should  omissions  have  been  made  the  documents  will  be 
returned  for  amendment,  in  order  to  render  them  valid.  In 
the  Appendix  {vide  p.  322)  will  be  found  the  forms  for  placing 
either  a  private  or  a  pauper  patient  under  care  and  treatment. 

The  Petition  is  a  request  to  a  Justice  to  grant  an  order 
for  the  reception  of  the  patient  to  a  particular  house,  private 
asylum,  registered  hospital,  or  public  asylum.  It  should  be 
signed  by  the  nearest  relative,  provided  the  age  is  at  least 
twenty-one  years ;  he  or  she  must  have  seen  the  patient 
within  fourteen  days  of  the  presentation  of  the  petition.  If 
any  other  person  signs  the  petition,  the  reason  must  be  given. 
It  has  annexed  to  it  a  Statement  (similar  to  that  used  for 
pauper  patients),  which  also  requires  the  signature  of  the  peti- 
tioner or  of  some  other  person,  containing  various  particulars 
concerning  the  patient,  including  the  name  of  the  usual  medical 
attendant,  if  any.  The  petitioner  must  sign  an  additional 
clause,  if  one  of  the  certificates  is  not  signed  by  the  usual 
medical  attendant. 

The  Medical  Certificates.- — Two  of  these  are  necessary, 
the  forms  being  practically  identical  with  those  for  paupers. 
The  certifiers  must  not  be  related  to  each  other,  or  be  partners  or 
assistants  one  to  the  other.     One  of  the  certificates  should. 


THE   LEGAL   RELATIONS    OF   INSANITY       267 

wherever  practicable,  be  signed  by  the  usual  medical  attendant, 
unless  he  is  to  act  as  the  visiting  medical  attendant  to  the 
patient  in  single  care. 

Neither  certificate  may  be  signed  by  any  resident  or  visiting 
officer  of  the  institution,  or  by  any  person  who  is  to  have 
charge  of  a  single  patient,  or  by  any  one  interested  in  the 
payments  on  account  of  the  patient,  or  by  any  near  relative, 
partner,  or  assistant,  of  the  foregoing.  The  certificates  must 
be  on  separate  sheets  of  paper,  and  the  certifiers  must  each 
personally  examine  the  patient,  separately  from  any  other 
practitioner,  and  at  a  time  not  more  than  seven  days  before 
the  presentation  of  the  petition  to  the  Justice. 

The  marginal  notes  should  be  read,  and  the  form  care- 
fully filled  up,  giving  the  full  name,  address,  and  occupation 
of  the  patient,  and  the  date  and  place  of  examination.  The 
certifier  will  observe  that  he  has  to  specify  that  the  patient  is 
a  person  of  unsound  mind  (or  a  lunatic  or  an  idiot)  and  a 
proper  person  to  be  taken  charge  of  and  detained  under  care 
and  treatment. 

Facts  indicating  Insanity  observed  at  the  examination  must 
be  stated,  such  as  the  appearance  and  attitude  of  the  patient, 
and  any  statements  or  actions  which  may  be  considered 
evidence  of  insanity  sufficient  to  satisfy  a  magistrate.  If  de- 
lusions are  present,  their  nature  should  be  described  in  the 
words  of  the  patient.  The  facts  must  be  such  as  to  bear  cross- 
examination  of  the  certifier  in  a  law  court.  Indefinite  or  irre- 
levant statements,  inferences  and  expressions  of  opinion  should 
not  be  made.  If  a  patient  does  not  answer  questions,  this  may 
in  some  cases  be  included  as  a  fact  provided  others  are  also  given. 
If  his  memory  appears  to  be  defective,  a  specific  instance  should 
be  given.  A  woman  may  state  she  is  pregnant  or  that  she  has 
recently  given  birth  to  a  child ;  this  may  be  a  delusion,  or  it 
may  be  true.  Again  if  a  patient  says  he  is  ruined  or  that  he 
has  committed  some  crime,  or  if  he  makes  accusations  of 
infidelity  against  his  spouse  or  says  he  is  persecuted  by  a 
certain  person,  some  qualifying  statement  should  be  added, 
such  as  "  which  is  not  the  case,"  or,  "  which  is  a  delusion." 
Facts,  which  the  certifier  has  observed  previous  to  the  time 
of  the  examination,  he  may  subjoin  in  a  separate  paragraph. 
There    is    no    need    to    fill    in    the    space    left    for    jacts 


268  MENTAL   DISEASES 

communicated  by  others,  if  the  certificate  is  strong  enough. 
Most  medical  men,  however,  do  so  to  reinforce  a  certificate. 
The  full  name,  address,  and  occupation  of  informants  must  be 
mentioned.  These  communicated  facts  indicating  insanity  must 
be  recent,  but  they  need  not  refer  to  the  date  of  examination 
by  the  certifier ;  they  may  be  corroborative  of  the  certifier's 
obtained  facts  or  may  be  entirely  different.  Care  must  be 
taken  that  no  ambiguity  occurs  in  the  use  of  pronouns.  It 
should  be  made  perfectly  clear  to  whom  they  refer. 

A  clause  provides  for  stating  whether  the  patient  is,  or  is 
not,  in  a  fit  bodily  state  to  be  removed.  Finally,  the  certi- 
ficate must  be  dated  and  signed ;  the  date  should  not  be  later 
than  seven  clear  days  from  the  time  of  examination,  and  the 
signature  of  the  certifier  should  be  accompanied  by  his  address, 
his  full  name  having  already  been  inserted  in  its  proper  place 
in  the  previous  part  of  the  form.  To  sign  such  a  certifi- 
cate a  medical  man  must  be  registered,  and  must  be  in  actual 
practice.  No  one  can  be  compelled  to  sign  a  certificate,  but 
with  the  protection  the  law  now  gives,  few  medical  men  raise 
any  objection.  It  need  hardly  be  mentioned  that  any  one 
who  makes  a  wilful  misstatement  in  a  certificate  is  guilty  of  a 
misdemeanour. 

The  Order  authorising  the  patient's  reception  as  a  person 
of  unsound  mind  must  be  signed  by  a  judicial  authority  who 
uses  his  discretion  as  to  his  seeing,  or  not  seeing  the  patient, 
after  he  has  examined  the  petition,  statement  and  certificates. 

The  judicial  authority  is  either  a  Justice  of  the  Peace,  a 
County  Court  Judge,  or  a  Stipendiary  Magistrate.  The  usual 
custom  is  for  the  relatives  or  the  medical  attendant  to  take 
the  documents  to  a  Justice  of  the  Peace,  who  has  been  specially 
appointed  under  the  Lunacy  Act.  Justices  who  are  willing 
to  act  are  appointed  annually,  and  a  list  can  generally  be  seen 
at  the  local  police  station,  or  at  the  union,  or  at  the  office  of 
the  clerk  to  the  magistrates.  Any  Justice,  however,  can  sign 
the  order,  but  it  requires  within  fourteen  days  the  endorse- 
ment of  one  specially  appointed.  Should  the  Justice  wish  to 
see  the  patient  before  making  the  order,  he  generally  does  so 
forthwith,  if  not  he  must  appoint  a  time  within  seven  days. 
After  seeing  the  patient  he  has  also  the  power  to  adjourn  the 
matter  for  a  period  not  later  than  fourteen  days,  or  he  may 


THE   LEGAL   RELATIONS    OF   INSANITY       269 

decline  to  make  the  order,  and  dismiss  the  petition,  giving  his 
reasons  in  writing  for  so  doing.  The  order  when  made  must 
be  executed  within  a  week,  or  it  lapses,  unless  suspended  by 
reason  of  the  patient  being  unfit  to  be  removed.  A  patient 
received  into  an  institution,  or  into  single  care,  without  having 
seen  a  Justice,  has  the  right  to  see  a  Justice,  unless  the  medical 
officer  certifies  to  the  Commissioners  within  twenty-four  hours 
of  the  patient's  reception,  that  it  would  be  prejudicial  to  him 
to  exercise  this  option. 

The  difficulty  and  loss  of  time  frequently  involved  in  finding 
a  Justice  to  sign  an  order  encourages  many  practitioners  to 
make  use  of  an  Urgency  Order. 

Urgency  Order. — This  is  an  authority  to  receive  a  patient, 
which  should,  whenever  practicable,  be  signed  by  a  relative. 
When  any  other  person  signs  an  urgency  order,  the  reason  for 
so  doing  must  be  mentioned.  It  has  a  Statement  of  par- 
ticulars annexed,  which  is  the  same  as  in  a  petition;  this 
statement  also  requires  signature.  It  must  be  accompanied 
by  a  Medical  Certificate  specifying  facts  indicating  insanity  in 
the  usual  form,  but  it  has  an  additional  Statement  by  the  certifier 
in  which  some  reasons  for  urgency  must  be  given.  It  is 
sufficient  to  say  that  a  patient  is  not  under  proper  control,  or 
refuses  food,  or  is  suicidal  or  violent,  as  the  case  may  be. 

The  certifier  must  have  examined  the  patient  within  tiuo 
clear  days  before  his  reception  under  care,  and  the  relative 
or  friend  who  signs  the  urgency  order  must  have  seen  the 
patient  "  within  two  days  before  signing  the  order,"  accordingly 
there  may  be  an  interval  of  some  days  between  these  two 
dates.  Practically,  it  means  that  an  urgency  medical  certificate 
lapses  after  two  clear  days,  if  the  patient  is  not  received  under 
care.  A  relative  seeing  the  patient  last,  say  on  Monday, 
March  17,  need  not  sign  an  urgency  order  till  Wednesday, 
March  19.  The  certifier  need  not  make  the  examination 
on  which  he  bases  his  facts  until  Monday,  March  24,  and  he 
may  date  his  certificate  on  that  day  (or  on  Tuesday,  March  25, 
or  Wednesday,  March  26),  assuming  that  Wednesday,  March  26, 
is  the  latest  day  for  the  legal  reception  of  the  patient. 

An  urgency  order  practically  remains  in  force  a  week 
only  after  reception,  during  which  time  the  second  certificate, 
the  petition,  and  the  judicial  order  must  be  secured,  otherwise 


270  MENTAL   DISEASES 

the  patient  must  be  discharged — unless  he  wishes  to  stay  as  a 
voluntary  boarder.  One  of  the  certificates  may  be  a  duplicate 
of  that  used  for  the  urgency  order. 

To  summarise  the  main  differences  in  the  ordinary  pro- 
cedure of  placing  a  pauper  and  a  private  patient  under  care  : — 

Pauper  Patient.  Private  Patient. 

Notice  to  relieving  officer  who  Petition    and     Statement     of 

informs  any  Justice  in  the  dis-  relative  or  friend,  who  calls  in 

trict,  and  signs  the  Statement,  two    practitioners    for    medical 

The    Justice    has    to    see    the  certification,    upon    which    the 

patient,  and  calls  in  a   practi-  Justice    (usually    one    specially 

tioner.     One  medical  certificate  appointed)     makes    the     Order 

only  is  required  to  accompany  ^^ith     or    mthout     seeing     the 

the  Summary  Reception  Order,  patient.    In  case  of  urgency,  the 

In  case  of  urgency,  the  pa-  patient's  relative  or  friend  signs 
tient  can  be  removed  to  the  an  Urgency  Order  and  State- 
workhouse  by  the  relieving  ment,  which  has  to  be  accom- 
officer,  poHce  or  overseer,  on  a  panied  by  one  medical  certificate 
'■  Three-Day  Order."  with  Statement  for  Urgency. 

On  recovery,  a  pauper  patient  is  discharged  by  the  com- 
mittee of  an  asylum  on  the  recommendation  of  the  medical 
officer.  The  committee  have  also  power  to  transfer  a  certified 
pauper  from  one  asylum  to  another,  or  to  board  him  out  by 
contract.  A  private  patient  is  discharged,  whether  recovered, 
relieved,  or  not  improved,  by  the  authority  of  the  petitioner, 
by  whom  also  he  may  be  transferred  elsewhere.  Should  the 
petitioner  have  died,  or  be  incapacitated,  another  one  may 
be  substituted,  or  else  the  person  who  made  the  last  payment 
may  act  instead,  or  again  the  discharge  may  be  ordered  by  the 
Commissioners. 

Appointment  of  Receiver. — A  petitioner  renders  him- 
self or  herself  liable  for  the  maintenance  of  a  patient  while 
under  care.  Sometimes  the  patient  has  already  given  a 
power  of  attorney  or  has  authorised  some  person  to  draw  on 
his  banking  account.  Strictly  speaking,  such  transactions 
should  cease  on  certification,  and  generally  no  arrangements 
have  been  made  at  all.  The  right  course  to  adopt  is  for  the 
petitioner  to  consult  a  solicitor  so  that  a  Receiver  may  be 
appointed  under  Sec.  116  of  the  Lunacy  Act.  This  entails  a 
medical  affidavit  to  support  the  copy  of  the  original  certificates, 
which  accompanies  the  summons  taken  out  in  chambers  at  the 


THE   LEGAL   RELATIONS    OF   INSANITY       271 

Royal  Courts  of  Justice  before  a  Master  in  Lunacy,  a  copy 
of  which  summons  has  to  be  served  at  least  seven  days 
beforehand  upon  the  patient ;  the  latter  usually  raises  no 
objection  to  the  appointment  of  the  Receiver.  This  pro- 
cedure costs  about  £20  or  more,  and  the  receivership  is 
cancelled  on  the  patient's  application  after  recovery.  The 
affidavit  of  a  medical  man  is  usually  required  when  a  person 
has  recovered  and  is  fit  to  manage  his  affairs.  A  word  of 
warning  must  be  given  as  regards  granting  a  certificate  of 
sanity  to  any  person  except  for  some  special  purpose,  and 
it  should  usually  only  be  given  after  a  repeated  examination 
of  the  patient,  and  a  careful  consideration  of  his  or  her  previous 
history,  taking  all  the  circumstances  into  account. 

Chancery  Patients. — In  the  case  of  a  patient  of  con- 
siderable means  who  objects  to  a  Receiver  being  appointed,  a 
Judge  in  Lunacy  may  direct  an  Inquisition  to  be  held  before 
one  of  the  two  Masters  in  Lunacy,  or  before  himself.  The  rela- 
tives may  also  apply  for  such  an  inquiry  to  be  made  with  regard 
to  a  patient,  provided  good  reason  is  shown.  The  procedure  is 
expensive,  and  a  patient  may  claim  to  be  examined  before  a 
jury  in  open  court  or  in  private.  Counsel  may  be  employed, 
and  evidence  is  received  covering  a  period  not  exceeding  two 
years  beforehand.  The  medical  witnesses  on  either  side  gener- 
ally include  experts  who  have  signed  certificates  or  affidavits 
regarding  the  patient. 

The  Court  may  find  one  of  three  verdicts  : — 

( 1 )  That  the  person  is  capable  of  managing  himself  and  his 
affairs. 

(2)  That  he  is  capable  of  managing  himself  but  not  his 
affairs,  or  vice  versa.  The  latter  decision  is  practically  never 
arrived  at. 

(3)  That  he  is  of  unsound  mind  and  incapable  of  managing 
himself  and  his  affairs. 

The  last  verdict  is  usual,  and  an  Inquisition  is  mostly 
confined  to  cases  unlikely  to  improve ;  but  in  the  case  of-  a 
patient  who  does  recover,  the  proceedings  are  set  aside  by 
another  legal  process  known  as  Sb  Supersedeas. 

In  the  case  of  a  patient  so  found  lunatic  by  Inquisition  any 
previous  certificates  are  thereby  quashed.      Committees  of  the 


272  MENTAL   DISEASES 

Person  and  of  the  Estate  are  appointed  (who  may  be  one  and 
the  same  mdividual)  and  the  patient  is  visited  biennially  by 
one  of  the  three  Lord  Chancellor's  Visitors  (of  whom  two  are 
medical  and  one  legal).  There  are  at  present  472  Chancery 
cases,  187  of  them  being  in  single  care,  and  for  the  latter 
the  Commissioners'-  books  need  not  be  kept,  but  notices  of 
reception  and  removal  must  be  sent  to  the  Lord  Chancellor's 
Visitors,  Royal  Courts  of  Justice,  Strand,  W.C.  When  received 
in  an  institution,  a  written  order  must  be  obtained  from  the 
Committee  of  the  Person,  together  with  an  '"'  office  copy  of  the 
order  appointing  such  Committee,"  and  the  admission  (and 
removal)  must  be  notified  to  the  Commissioners  as  in  the  case 
of  other  patients,  as  well  as  to  the  Lord  Chancellor's  Visitors. 

Public  Asylums. — These  are  the  large  county  or  borough 
asylums,  about  ninety  in  number,  built  and  maintained  out  of 
the  rates,  the  expenses  of  which  are  to  a  small  extent  refunded 
to  the  Guardians  by  the  patient's  relatives,  whenever  this  is 
possible.  The  patients  are  nearly  all  of  the  pauper  class. 
There  is  also  a  special  asylum  for  the  Army  (at  Netley)  and 
one  for  the  Navy  (at  Yarmouth),  besides  the  two  Criminal 
asylums  (Broadmoor  and  Pampton). 

Registered  Hospitals  for  Mental  diseases,  of  which  there 
are  fourteen  in  England,  are  managed  by  Committees,  and  are 
maintained  by  the  charges  paid  by  patient's  relatives,  by  sub- 
scriptions and  donations,  and  by  endowments.  They  are 
larger  than  private  asylums,  and  are  mostly  designed  to  under- 
take charitable  work  for  private  patients  of  the  educated 
classes  with  small  means. 

Private  Asylums  are  special  establishments  licensed  by 
the  Commissioners  in  the  Metropolitan  area,  and  by  Justices 
in  the  Provinces.  There  are  twenty  in  the  former  area,  and 
forty  in  the  latter.  With  the  exception  of  two  large  "  Houses  " 
which  accommodate  paupers  also,  they  are  confined  to  private 
patients  only  and  those  mostly  of  the  upper  classes.  The  lay 
proprietorship  has  latterly  almost  entirely  been  superseded  by 
medical  control,  and  their  privacy  appeals  to  the  public  and 
profession  alike. 

Particulars  as  to  registered  hospitals,  public  and  private 
asylums,  can  be  obtained  from  the  Medical  Directory. 

Voluntary  Boarders  of  either  sex  are  received  for  treat- 


THE   LEGAL   RELATIONS   OF   INSANITY       273 

merit  in  registered  hospitals  and  private  asylums  (but  not  in 
county  or  borough  asylums) ;  sometimes  relatives  or  com- 
panions of  patients  are  also  admitted  as  such.  Boarders  must 
not  be  certifiably  insane,  and  neither  suicidal  nor  dangerous. 
They  must  be  allowed  to  leave,  if  they  wish,  on  giving  twenty- 
four  hours'  notice.  For  their  reception,  application  to  the  com- 
mittee of  a  registered  hospital  is  sufRcient,  but  in  the  case  of  a 
private  asylum,  the  applicant  must  write  a  letter  beforehand 
to  the  Commissioners  or  Visiting  Justices,  which  must  be  accom- 
panied by  a  medical  report. 

Single  Care. — This  may  be  in  the  official  charge  of  a 
person  in  the  patient's  own  house,  or  in  the  house  of  a  doctor 
or  layman.  There  are  at  present  about  540  of  these  certified 
cases,  most  of  them  being  of  the  female  sex.  Under  special 
circumstances  the  Commissioners  grant  permission  for  two  or 
more  certified  patients  in  one  house  (Sec.  46  of  the  Act).  If 
the  practitioner  attending  the  patient  is  to  continue  as  the 
statutory  medical  attendant  in  single  care,  he  must  not  be  one 
of  the  certifjdng  physicians. 

Legal  Duties  of  the  Person  in  Charge  of  an  Insane 
Patient. — With  the  exception  of  a  Chancery  patient  in  single 
care,  it  is  necessary,  within  one  clear  day  of  the  reception  of 
a  private  certified  patient,  whether  into  an  institution  or  not, 
to  send  notice,  with  a  copy  of  the  admission  papers,  to  the 
Secretary  to  the  Commissioners  of  the  Board  of  Control,  at 
66  Victoria  Street,  S.W.  In  the  case  of  an  ordinary  single 
patient  full  instructions  will  be  sent  from  that  office.  A  Medical 
Journal  has  to  be  kept  (which  can  be  procured  from  Shaw  &  Sons, 
Fetter  Lane,  E.C.),  and  has  to  be  produced  to  any  Commis- 
sioner when  he  visits  the  house  or  institution.  If  the  person 
in  charge  of  a  single  patient  is  a  medical  man,  another  medical 
practitioner  has  to  visit  the  patient,  and  must  send  to  the 
office  the  medical  statement  which  is  required  not  less  than 
two  days  and  not  more  than  seven  days  after  the  reception  of 
every  patient.  The  medical  attendant  of  a  single  patient  has 
to  visit  the  patient  once  a  fortnight,  and  a  medical  report  is 
necessary  at  the  expiration  of  a  calendar  month  after  reception. 
The  medical  visits  may  be  at  longer  intervals  in  chronic  cases, 
by  special  permission  from  the  central  office.  Notice  of  dis- 
charge on  recovery  or  not,  or  of  removal,  or  of  death  has  to  be 

T 


274  MENTAL   DISEASES 

sent  to  the  Commissioners  within  two  days,  and  in  the  case 
of  death,  to  the  Coroner  also.  If  the  patient  remains  under 
care  for  a  prolonged  period,  to  prevent  the  original  reception 
order  from  lapsing  a  special,  i.  e.  continuation  report  must  be 
sent  not  more  than  one  month  nor  less  than  eight  days  before 
the  expiration  of  the  first,  second,  fourth,  and  seventh  years 
respectively,  and  then  at  a  similar  interval  before  the  expira- 
tion of  every  successive  five  years.  These  notices  and  reports 
are  required  in  the  case  of  every  certified  patient,  whether  in 
an  institution  or  in  single  care.  An  extra  report  is  also  neces- 
sary in  the  case  of  a  single  care  patient  in  the  middle  of 
January  of  each  year. 

With  regard  to  the  admission  of  pauper  patients  to  asylums, 
notice  has  to  be  sent  within  a  week  to  the  Commissioners, 
together  with  a  copy  of  the  reception  papers,  and  the  medical 
statement. 

A  patient  may  be  allowed  forty-eight  hours'  leave  of  absence 
by  the  person  in  charge,  or  by  the  medical  officer  of  an  insti- 
tution. For  longer  periods,  or  for  trial,  a  medical  recom- 
mendation and  a  letter  of  approval  from  the  petitioner  are 
requisite  to  obtain  official  consent  from  the  Commissioners  or 
Visiting  Justices  in  private  asylums  and  single  care,  or  from  the 
the  committee  of  a  registered  hospital  or  county  asylum.  Permis- 
sion is  not  usually  granted  to  travel  out  of  England  or  Wales. 

If  a  patient  escapes,  or  extends  his  term  of  absence  without 
sanction,  he  may  be  recaptured  within  fourteen  days.  Due 
notice  of  both  events  must  be  sent  to  the  Commissioners.  A 
private  patient  can  be  transferred  from  one  asylum  or  single 
care  to  another,  on  the  order  of  the  responsible  relative  or 
guardian,  and  with  the  consent  of  the  Commissioners. 

Seclusion,  if  resorted  to — i.e.  locking  a  patient  in  a  room  alone 
between  the  hours  of  seven  a.m.  and  seven  p.m. — must  be 
recorded.  Mechanical  restraint,  if  ever  found  necessary  to 
prevent  injury  to  the  patient  or  to  others,  must  be  likewise  re- 
corded. Only  appliances  permitted  by  the  Commissioners  may 
be  used,  such  as  a  strait-jacket,  special  gloves,  the  wet  and 
dry  pack,  etc.  Ill-treatment,  or  wilful  neglect  of  a  patient  is 
punishable  by  fine,  or  imprisonment,  or  by  both,  whilst  any  one 
conniving  at  a  patient's  escape  is  also  liable  to  be  fined.  As  to 
correspondence,  patients'  letters  must  be  sent  unopened  to 


THE   LEGAL   RELATIOXS    OF   INSANITY       275 

certain  authorities,  including  the  Lord  Chancellor,  Secretaries 
of  State,  the  Commissioners,  the  Visiting  Committee,  the  Justice 
who  signed  the  order,  and  the  petitioner  (Sec.  41).  Others 
are  sent  at  the  discretion  of  the  person  in  charge. 

The  Mental  Deficiency  Act,  which  comes  into  operation 
on  April  1,  1914,  will  supersede  the  Idiots  Act  of  1886,  under 
which  about  2000  patients  are  cared  for.  Its  scope  is  devised 
to  include  the  congenitally  feeble-minded  and  moral  defectives, 
in  addition  to  imbeciles  and  idiots. 

Under  this  Act  a  person,  who  is  a  defective  (according  to 
the  definitions  already  given  in  the  Chapter  on  "  Amentia  '""), 
may  be  dealt  with  by  being  sent  to,  or  placed  in,  a  certified 
house  or  institution  for  defectives,  or  placed  in  an  approved 
home,  or  under  guardianship. 

This  may  be  undertaken  at  the  instance  of  the  parent  or 
guardian  if  the  defective  is  an  idiot  or  imbecile,  or  is  under 
the  age  of  twenty-one.  Besides  the  statement  of  the  parent 
or  guardian,  two  medical  certificates  are  necessary,  one  of  which 
must  be  supplied  by  a  practitioner  approved  either  by  the  local 
authority  under  the  Act  or  by  the  Board  of  Control,  and  in  the 
case  of  the  congenital  feeble-minded  or  moral  defective,  must 
be  countersigned  by  a  judicial  authority.  Within  seven  days, 
notice  of  reception,  with  a  copy  of  the  documents,  must  be 
sent  to  the  Secretary  to  the  Commissioners  of  the  Board  of 
Control.  Subject  to  certain  provisions,  the  defective  may  be 
discharged  at  any  time  by  the '  relative  or  guardian,  and  a 
special  certificate  is  required  at  the  end  of  the  first  year,  and 
thereafter  at  the  expiration  of  every  five  years,  for  the 
continued  care  of  a  defective. 

A  defective  may  also  be  sent  to  a  certified  house  or  insti- 
tution or  to  a  State  institution  on  an  order,  if  he  is  a  person  who 
is  neglected  or  cruelly  treated,  or  who  is  found  guilty  of  a 
criminal  offence,  or  who  is  liable  to  be  sent  to  an  industrial 
school,  or  is  detained  therein,  or  is  detained  in  an  inebriate 
or  other  reformatory,  or  in  prison,  or  in  an  asylum,  or  who  is 
an  habitual  drunkard,  or  who  is  in  receipt  of  poor  relief  when 
pregnant  or  when  giving  birth  to  an  illegitimate  child,  or  in  whose 
case  notice  has  been  given  by  the  educational  authority  that 
a  child  over  the  age  of  seven  is  incapable  of  receiving  benefit  in 
a  special  school,  or  if  at  the  age  of  sixteen  such  defective  needs 


276  MENTAL   DISEASES 

further  protection  in  a  house  or  institution,  or  under  guardian- 
ship.    The  order  may  be  that  of  a  judicial  authority  (who  has 
seen  the  defective)  on  the  petition  of  a  relative  or  friend,  or  of  an 
officer  of  a  local  authority,  which  petition  must  be  accompanied 
by  a  statement,  and  tivo  medical  certificates,  one  of  which  must 
be  from  a  practitioner  approved  either  by  the  local  authority  or 
by  the  Board  of  Control  (or  a  certificate  that  a  medical  exami- 
nation was  impracticable),  or  the  order  may  be  that  of  a  Court 
or  of   the  Home   Secretary.     Such  orders  require    execution 
within  a  fortnight,  and  they  last  one  year,  when  they  can 
be   continued,    by   a   special   certificate,   which   is   thereafter 
requisite  at  the  expiration  of  every  five  years.     Notice  of  re- 
ception, with  a  copy  of  the  documents,  will  no  doubt  have  to 
be  sent  to  the  Board  of  Control,  in  whose  hands  also  the  dis- 
charge, transfer,  or  leave  of  absence,  of  such  defectives  is  largely 
vested,  but  regulations  are  to  be  shortly  issued  by  the  Home 
Secretary  for  the  proper  working  of  the  Act.     The  same  rules 
as  to  restraint,  correspondence,  escape,  etc.,  apply;  also  pro- 
tection  and   penalties  obtain    under   this  Act    as  under  the 
Lunacy  Act,  and  a  special  clause  relates  to  sexual  immorality, 
procuration,  etc.     State  institutions  are  to  be  inaugurated  by 
the  Board  of  Control;  the  eight  voluntary  idiot  establishments 
are  to  be  certified  institutions  under  the  Act  and  the  local 
authority  will  receive  as  before  a  grant  from  the  Central  Ex- 
chequer (probably  about  75.  per  pauper  defective).     Approved 
homes  can  also  be  established  for  patients  not  under  judicial 
order.      These,  with  the  certified  houses,  and  institutions,  are 
to  be  subject  to  visitation  by  the  Commissioners  and  Inspectors 
of  the  Board  of  Control,  and  by  other  statutory  Visitors. 

Power  is  also  given  for  the  transfer  of  defectives  from 
institutions  for  the  insane  to  those  under  this  Act,  and  vice 
versa,  although  presumably  idiots  and  imbeciles  can  still  be 
received  in  the  institutions  under  the  Lunacy  Act  as  before. 
The  judicial  authority  is  the  same  as  under  the  Lunacy 
Act,  as  is  also  the  local  authority,  but  at  least  two  women  are 
to  serve  on  the  special  Committee  of  the  latter.  It  devolves 
upon  the  local  authority  to  ascertain  what  persons  within  their 
area  are  defectives,  subject  to  be  dealt  with  under  the  Act, 
and  to  provide  suitable  provision  for  them.  It  also  becomes 
compulsory  for  the  local  education  authority  to  ascertain  what 


THE   LEGAL   RELATIONS    OF   INSANITY       277 

children  are  defective,  and  to  notify  those  who  are  unable  to 
receive  benefit  or  instruction  in  the  special  schools. 

The  Central  Authority  for  the  supervision  of  the  insane 
and  mentally  defective  is  vested  in  the  Board  of  Control,  which 
consists  of  fifteen  Commissioners — four  medical,  four  legal 
members,  and  two  women  amongst  them ;  the  office  of  the 
Board  is  at  66  Victoria  Street,  S.W.  Visits  are  made  by  them, 
or  by  their  Inspectors  and  other  Visitors  to  all  asylums  and 
houses  receiving  the  insane  and  mental  defectives.  They 
have  power  also  to  prosecute  for  non-compliance  with  the 
Lunacy  and  Mental  Deficiency  Acts.  They  report  annually 
to  the  Lord  Chancellor,  who  is  at  present  the  supreme  authority 
in  all  matters  regarding  the  insane,  and,  through  his  Visitors 
and  the  Masters  in  Lunacy,  has  the  protection  of  patients  ^\ith 
property. 

The  student  who  desires  further  acquaintance  with  the 
existing  legislation  affecting  the  insane  and  mentally  defective, 
should  consult  the  Lunacy  and  Mental  Deficiency  Acts,  which 
can  be  obtained  from  Eyre  &  Spottiswoode,  East  Harding 
Street,  E.C. 

The  Channel  Islands  and  the  Isle  of  Man  have  each  a 
separate  jurisdiction  in  Lunacy.  No  magistrate's  order  is 
required  for  a  private  patient  in  these  islands. 

In  Scotland,  insane  persons,  and  also  idiots  and  imbeciles 
above  eighteen  years  of  age,  whether  private  or  pauper,  are 
placed  in  institutions  by  an  order  of  a  Sheriff  on  a  petition 
and  statement,  and  two  medical  certificates,  provided  the 
latter  are  signed  on  the  date  of  examination.  In  the  case  of 
a  pauper,  the  petitioner  is  the  Inspector  of  the  Poor.  An 
emergency  order  lasting  three  days  can  also  be  given  by  a 
relative  or  friend  on  one  medical  certificate.  There  are  both 
public  and  private  asylums.  The  former  are  called  district 
asylums  and  are  designed  for  paupers,  whilst  the  Royal 
asylums  compare  with  registered  hospitals.  A  private  patient 
deemed  curable  can  be  treated  in  single  care  for  six  months 
without  formal  certification  on  medical  recommendation, 
provided  the  Scotch  Commissioners  are  notified,  a  further  ex- 
tension for  another  six  months  being  sometimes  granted.  The 
property  of  patients  can  be  placed  by  the  Court  in  the  hands 
of  a  Curator.     Uncertified  persons  who  are  prodigal  or  facile 


278  MENTAL   DISEASES 

can,  in  Scotland,  be  prevented  from  losing  or  giving  away  their 
property  by  the  legal  process  known  as  Interdiction.  Legis- 
lation has  been  recently  provided  for  Mental  Defectives  similar 
to  that  enacted  for  England. 

In  Ireland,  lunacy  legislation  is  both  cumbrous  and 
archaic.  Pauper  patients  are  largely  detained  in  prisons  at 
first,  and  are  then  removed  on  warrants  to  the  district  or  public 
asylums.  There  is,  however,  provision  made  for  the  reception 
of  both  private  and  pauper  patients  by  means  of  a  declaration 
before  a  magistrate,  a  certificate  of  a  magistrate,  clergyman, 
or  poor  law  guardian,  one  medical  certificate  (which  in  paying 
patients  requires  the  signatures  of  two  medical  men)  and  an 
obligation  on  the  part  of  the  relatives  as  to  removal  of  the 
patient  where  necessary,  and  as  to  payment.  Private  patients 
are  received  in  private  asylums  or  in  single  care  on  the  order 
of  a  relative,  accompanied  by  one  medical  certificate,  which 
must  be  signed  by  two  medical  men.  In  cases  of  urgency, 
one  signature  suffices,  but  a  second  is  requisite  within  fourteen 
days.  Inquisition  proceedings  resemble  those  in  England. 
There  is  no  special  legislation  for  Mental  Defectives. 

The  Inebriates  Act,  1898. — An  inebriate,  who  is  not 
mentally  defective,  can  only  be  detained  in  a  retreat  at  his  own 
request,  and  for  a  specified  period  of  detention  not  exceeding 
twelve  months.  He  must  have  signed  the  requisite  document 
before  a  magistrate  prior  to  his  reception.  This  requires  also  a 
declaration  before  a  Justice  or  Commissioner  of  Oaths  to  be 
signed  by  two  friends  of  the  inebriate  that  he  is  a  proper  subject 
for  treatment ;  the  prescribed  forms  can  be  obtained  from  any 
licensed  retreat.  Voluntary  treatment  without  detention  is, 
however,  permissible.  There  is  unfortunately  no  inebriate 
retreat  for  the  destitute  poor.  A  person  who  is  an  habitual 
drunkard,  guilty  of  crime,  or  who  has  been  convicted  of  minor 
offences  four  times  in  twelve  months,  may  be  detained  in  a 
certified  or  State  inebriate  reformatory  for  a  term  not  exceed- 
ing three  years.  With  certain  modifications  the  Act  applies 
also  to  Scotland  and  Ireland.  Particulars  as  to  retreats  may 
be  obtained  from  the  Medical  Directory. 

2.  Testamentary    Capacity 

The  law  presupposes  that  a  person  who  makes  a  valid 
will  should  possess  "  a  sound  and  disposing  mind." 


THE   LEGAL   RELATIONS    OF   INSANITY       279 

In  the  Interpretation  of  this  expression,  however,  it  has 
been  held  that  a  patient  may  be  certifiably  insane,  or  even  be 
a  Chancery  patient,  and  yet  possess  sufficient  capacity  to  make 
a  vaHd  will,  whilst  a  person  not  regarded  as  insane  in  the 
ordinary  sense,  may  not  have  a  sound  and  disposing  capacity 
by  reason  of  weakness  or  disorder  of  mind  from  various  causes. 
Probate  of  a  will  is  granted  to  the  executors  provided  they 
show  that  the  testator  possessed  adequate  capacity,  and  had 
proper  knowledge  of  the  contents  of  the  will  and  approved  of 
them,  and  that  the  will  was  executed  in  due  form. 

In  cases  of  dispute  it  must  be  said  that  the  Court  requires 
ample  evidence  to  upset  a  will.  It  may  contain  strange  senti- 
ments, and  legacies  may  be  left  disappointing  expectant 
relatives,  yet,  if  it  was  the  patient's  "  will  "  so  to  do,  and  he 
possessed  sufficient  capacity  to  give  instructions  for  the  draft 
and  for  its  execution,  it  will  probably  be  pronounced  valid. 
The  law  is  such  that,  in  the  case  of  persons  dying  intestate, 
their  property  is  distributed  amongst  their  dependants  and 
nearest  relatives  in  what  is  considered  a  right  proportion.  The 
idea  of  making  a  will  is,  therefore,  discouraged  amongst  the 
insane.  Yet  a  certified  patient  who  insists  on  making  a  will 
cannot  be  denied  the  right  to  do  so,  or  to  execute  a  codicil  to 
a  former  will.  These  cases  are  very  exceptional,  and  it  is 
always  wise  to  acquaint  the  legal  guardians  of  such  patients 
of  these  proceedings.  There  may  indeed  be  grounds  for  dis- 
puting the  will  after  death,  and  in  any  case  testamentary 
capacity  will  have  to  be  proved. 

On  the  other  hand,  persons,  who  in  other  respects  have 
been  regarded  as  sane,  have  had  their  wills  successfully  dis- 
puted by  it  being  proved  that  they  were  at  the  time  "  facile  " 
and  easily  influenced.  This  may  happen  from  bodily  disease 
or  infirmity,  from  old  age,  by  reason  of  loss  of  memory,  or  from 
inability  to  express  themselves  intelligibly  by  speech,  writing, 
or  signs.  Some  cases  of  aphasia,  however,  may  give  evidence 
of  competence.  If  the  testator  had  delusions,  it  must  be 
shown  that  they  directly  influenced  or  affected  the  disposal 
of  the  person's  means.  The  same  applies  also  to  morbid  sus- 
picions and  poisoned  affections.  A  person  may  be  highly 
endowed  and  capable  of  transacting  business,  yet,  he  may  not 
be  able  to  make  a  valid  will. 

No  idiot,  imbecile,  or  congenitally  feeble-minded  person  of 


280  MENTAL   DISEASES 

mature  years,  i.  e.  a  person  mentally  weak  from  birth  or  early 
life,  can  make  a  valid  will,  and  the  same  disability  applies  to 
any  person  under  the  age  of  twenty-one  years.  A  decision  as 
to  testamentary  capacity  is  difficult  for  most  medical  men, 
especially  in  recurrent  cases  of  insanity  when  a  so-called 
lucid  interval  may  exist,  and  a  person  wishes  to  make  a  will. 
It  is  unwise  for  a  medical  man  to  sign  as  a  witness  to  a 
will  in  any  doubtful  case ;  thereby  he  implies  that,  in  his 
opinion,  the  testator  is  competent.  He  should  make  himself 
conversant  with  the  contents  of  such  a  will,  and  if  asked  to 
support  it,  he  should  make  a  careful  examination  of  the  tes- 
tator apart  from  relatives.  It  may  be  best  to  see  him  more 
than  once,  and  perhaps  advise  a  ^  consultation  with  another 
medical  man.  Careful  notes  should  be  made.  He  should  be 
sure  that  the  testator  is  not  under  the  influence  of  alcohol  or 
drugs,  and  that  he  is  not  unduly  biassed  by  any  one.  He 
should  test  the  memory  for  both  recent  and  remote  events.  He 
should  ask  him  if  he  has  made  a  will  before,  and  if  so  why  he 
wishes  to  alter  it  ?  He  should  examine  particularly  for  any 
indication  of  mental  weakness,  or  disorder,  and  for  unfounded 
suspicions  against  any  of  his  relatives.  He  should  satisfy 
himself  whether  the  testator's  likes  or  dislikes  for  certain 
relatives  or  friends  are  based  on  rational  grounds,  or  are  the 
result  of  mental  disorder. 

He  should  ascertain  if  he  understands  fully  :— 

(1)  The  nature  of  his  act  and  its  consequences,  viz.  that  he 
is  making  a  will  to  take  effect  after  his  death. 

(2)  The  approximate  estimate  of  the  nature  and  extent  of 
his  property. 

(3)  The  proportionate  claims  of  his  different  relatives. 
He  should  find  out  if  the  testator  can  enumerate  his  relatives 
and  realise  those  he  is  including  and  those  he  is  excluding  (if 
any).  If  he  knov/s  in  what  manner  he  is  leaving  his  property, 
and  if  he  can  recapitulate  the  contents  of  his  will. 

Generally  speaking,  the  four  conditions  that  may  interfere 
with  a  sound  and  disposing  capacity  for  making  a  valid  will 
are  : — 

(1)  Morbid  influence,  by  unfounded  suspicions  or  insane 
delusions  affecting  the  will. 

(2)  Impairment  of  the  mental  faculties  by  old  age. 


THE   LEGAL   RELATIONS    OF   INSANITY       281 

(3)  Mental  weakness  from  bodily  disease. 

(4)  Congenital  incapacity,  i.  e.  idiocy,  imbecility,  or  feeble- 
mindedness. 

In  cases  of  severe  illness,  sometimes  a  patient  is  anxious 
to  make  a  will.  The  medical  attendant  should  satisfy  himself 
that  the  patient's  mind  is  sufficiently  unclouded  to  admit  of  his 
understanding  the  provisions  of  the  will  and  of  his  being  able 
to  recapitulate  them. 

Disputed  wills  are  generally  tried  before  a  Judge  and  Jury 
who  will  expect,  from  a  medical  witness,  facts  on  which  his 
opinion  of  the  testator's  competence  or  mcompetence  is 
based. 

3.  Civility  Liability- 
Contracts. — In  the  case  of  an  engagement  to  marry,  the 
betrothal  can  be  broken  off  if  either  party  becomes  insane. 
If  marriage  has  taken  place,  either  by  ceremony  in  a  church, 
or  before  a  registrar,  and  if  one  of  the  parties  can  prove  that 
either  of  them  at  the  time  of  marriage  was  mentally  disordered, 
and  did  not  comprehend  the  contract  and  the  nature  of  the 
duties  and  responsibilities  pertaining  thereto,  it  can  be  arm.uUed 
in  the  Divorce  Court ;  or  again  if  it  can  be  proved  that  one 
party  did  not  know  at  the  time  of  marriage  of  the  other  party's 
insanity,  a  decree  of  nullity  can  be  obtained.  When,  how- 
ever, insanity  supervenes  after  matrimony,  the  contract 
cannot  be  dissolved  by  reason  of  mental  disease  only.  In- 
sanity also  cannot  be  raised  in  defence  of  adultery,  or  other 
breaches  of  the  marriage  law. 

Other  contracts  cannot,  as  a  rule,  be  broken  by  reason 
of  a  person's  insanity.  If,  however,  a  person  is  insane,  or 
incompetent  through  drink,  and  incurs  expenses  or  procures 
"  necessaries,'"  such  liabilities  are  voidable  at  the  instance  of 
the  insane  or  incompetent  party,  provided  it  can  be  proved 
that  the  other  party  was  aware  of  his  insanity  or  incom- 
petence and  irresponsibilit5^ 

Libel :  Slander  :  Trespass  and  other  wrongs  by  which 
one  party  is  injured  in  person,  character,  or  property  by 
another,  are  not  excusable  on  the  ground  of  insanity.  The 
insane  person  is  liable,  but  a  jury  usually  awards  nominal 
damages  only. 


282  MENTAL   DISEASES 

Witnesses. — An  insane  person's  evidence  is  sometimes 
accepted  in  a  law  court,  in  which  case  it  is  left  to  the  Judge 
and  Jury  to  decide  how  far  it  maybe  regarded  as  reliable. 

4.  Criminal  Responsibility- 
Punishment,  deterrent  and  reformatory,  should  be,  and  is 
generally  meted  out  according  to  the  culpability  of  the  prisoner. 
In  the  case  of  offences  and  crimes  that  are  due  to  mental 
disease  the  existence  of  the  latter  is  rightly  regarded  as  a  reason 
for  absolving  a  prisoner  whose  insanity  is  really  responsible  for 
the  act  committed.  The  law  with  regard  to  the  criminal  re- 
sponsibility of  the  insane  is  founded  on  answers  to  questions 
put  by  the  House  of  Lords  to  the  Judges  in  1843.  These  ques- 
tions arose  from  public  feeling  excited  by  the  acquittal,  on  the 
ground  of  insanity,  of  MacNaughten  who  had  shot  Mr.  Drum- 
mond.  Sir  Robert  Peel's  private  secretary,  believing  him  to 
be  the  Prime  Minister  himself.  MacNaughten  was  a  Para- 
noiac, who  committed  the  crime  to  draw  attention  to  his 
imaginary  grievances.  He  was  afterwards  sent  to  Bethlem  as 
a  criminal  lunatic,  where  he  ultimately  died. 

These  answers  may  be  summarised  as  follows  :  That  to 
establish  a  defence  on  the  ground  of  insanity  it  must  be  proved 
that  at  the  time  of  committing  the  act,  the  party  accused  was 
labouring  under  such  defect  of  reason  from  disease  of  the 
mind,  as  not  to  know  the  nature  and  quality  of  the  act  he 
was  doing,  or  if  he  did  know  it,  that  he  did  not  know  he  was 
doing  what  was  wrong.  This  is  the  legal  test  of  insanity  as 
applied  to  criminal  cases,  the  phraseology  of  which  has  been 
much  assailed  by  the  medical  profession.  There  are  un- 
doubtedly insane  persons  who  understand  the  nature  and 
quality  of  their  actions  and  can  appreciate  the  difference 
between  right  and  wrong,  and  yet  who  may  not  be  able  to 
control  their  morbid  impulses. 

An  elastic  interpretation,  however,  is  generally  put  upon 
the  expression  "  knowing  "  the  nature  and  quality  of  an  act 
and  "  knowing  "  that  it  was  wrong,  by  most  judges,  and 
although  the  legal  criterion  is  antiquated  and  unsatisfactory, 
justice  on  the  whole  is  done.  Insane  persons  are  not  hanged, 
and  when  committed  to  prison,  their  condition  is  soon  recognised, 
and  they  are  sent  on  to  asylums. 


THE   LEGAL   RELATIONS    OF   INSANITY       283 

The  law,  moreover,  does  not  entirely  exonerate  an  insane 
person  for  every  offence  that  he  may  commit,  but  only  for  an 
act  that  would  be  permissible  under  certain  circumstances  in  a 
deluded  individual.  If,  on  the  one  hand,  the  layman  and  jurist 
is  apt  to  compare  a  prisoner  with  ordinary  people,  it  must  be 
remembered  that,  on  the  other  hand,  the  medical  man  is  in- 
clined to  compare  him  with  diseased  and  disordered  persons. 
There  is  no  criminal  heredity  allied  to  insane  inheritance,  and 
no  one  of  repute  would  give  such  evidence  as  to  shield  a  culprit 
from  the  punishment  that  is  his  due. 

When  examining  a  prisoner,  the  medical  man  should  make 
notes,  which  he  will  be  entitled  to  refer  to  in  the  witness  box. 
Questions  should  never  be  asked  implying  that  the  crime  was 
committed  by  the  prisoner,  but  the  circumstances  may  be 
discussed,  and  it  is  as  well  that  he  should  mention  any  of  the 
prisoner's  conversation,  indicating  insanity,  in  his  own  words. 
He  should  be  on  his  guard  against  any  feigned  insanity  or 
epilepsy.  He  should  go  at  length  into  the  prisoner's  past  history. 
Sometimes  the  judge  will  permit  facts  to  be  brought  up  as  to  the 
family  history,  if  there  be  any  neuropathic  heredity^epilepsy, 
insanity,  etc.  Although  it  may  not  be  strictly  according  to 
law,  the  judge  may  ask  the  medical  witness  (especially  if  he  is 
an  expert)  for  his  opinion  on  the  case,  besides  his  statement  of 
facts.  It  is,  however,  best  for  him  to  confine  his  attention  to 
facts  indicating  the  insanity  of  the  prisoner,  and  not  to  give  an 
expression  of  opinion  as  to  responsibility,  as  this  is  a  legal 
matter  and,  therefore,  one  which  should  be  left  to  the  jury. 

A  case  having  been  sent  for  trial,  the  prisoner  may  be 
considered  by  the  jury  to  be  insane  and  unfit  to  plead,  or  his 
insanity  may  be  raised  as  a  defence  in  the  later  stages.  If  he 
is  acquitted  on  the  ground  of  insanity,  or  rather  found  guilty 
but  insane,  he  is  not  allowed  to  go  free  but  is  sent  to  one  of 
the  criminal  asylums,  during  His  Majesty's  pleasure.  These 
are  prison  asylums  for  all  classes,  and  here  also  are  received 
insane  criminals,  i.e.  convicts  who  have  developed  insanity ; 
but  as  the  accommodation  is  limited,  many  of  the  latter  un- 
fortunately have  to  be  admitted  to  county  asylums,  and  on 
their  recovery  are  sent  back  to  prison  to  finish  their  sentences. 

Criminal  offences  amongst  the  insane  occur  mostly  in  early 
Paranoiacs,  Melancholiacs,  Puerperals,  Alcoholics,  Epileptics, 


284  MENTAL   DISEASES 

General  Paralytics,  Senile  Dements,  in  cases  of  Impulsive  In- 
sanity (Psychasthenia)  and  of  Moral  Insanity  (or  Imbecility). 
The  more  common  offences  are  assaults,  attempted  suicide,  and 
indecent  exposure.  Cases  such  as  infanticide,  homicidal  acts, 
arson,  larceny,  and  sexual  crimes,  are  usually  sent  for  trial,  as  a 
police  court  has  no  power  to  deal  with  the  defence  of  insanity. 
A  magistrate  does,  however,  sometimes  dismiss  a  case  and  allow 
the  patient  to  be  handed  over  to  the  charge  of  relatives  if  the 
signs  of  insanity  are  unmistakable,  and  a  guarantee  is  forth- 
coming that  the  patient  will  be  placed  under  care.  The 
evidence  of  the  family  medical  attendant  in  such  a  case  is 
always  of  the  utmost  service.  In  minor  offences  the  inspector 
at  the  police  station  does  not  always  enter  a  case  on  the  charge 
sheet,  and  directs  the  constable  to  take  the  patient  to  the 
workhouse  infirmary  on  a  three-day  order. 

Moral  Insanity  (or  Imbecility)  is  invariably  a  stumbling 
block  to  lawyers,  who  usually  regard  it  as  a  physician's  defi- 
nition of  unmitigated  depravity,  and  fail  to  realise  that  insanity 
can  exist  without  delusions.  The  mental  standards  of  criminals 
vary,  however,  some  being  undoubtedly  weak-minded,  others 
not  at  all,  and  others  again  being  on  the  border-line ;  in  the 
last  case  opinions  may  differ,  as  to  whether  vice  is,  or  is  not, 
disease  ;  whilst  in  the  case  of  the  weak-minded  criminal,  it  must 
be  pointed  out  that  in  all  his  actions  he  is  not  altogether  to  be 
regarded  as  irresponsible. 

Drunkenness  is  by  common  consent  considered  no  excuse 
for  crime,  but  in  the  case  of  Delirium  Tremens  or  Alcoholic 
Insanity  the  person  is  usually  absolved.  Larceny  is  some- 
times committed  by  the  insane,  especially  in  General  Paralysis 
and  Senile  Dementia.  The  theft  is  usually  done  clumsily, 
worthless  articles  may  be  taken,  and  are  frequently  given 
away  again  or  lost.  Although  the  condition  known  as  Klepto- 
mania exists,  it  must  be  confined  within  proper  limits,  and  a 
neuropathic  inheritance  should  be  expected  in  a  genuine  case ; 
a  common  thief  does  occur  now  and  then  in  the  upper  classes 
of  society,  and  such  a  one  is  deserving  of  punishment  rather 
than  of  commiseration. 

Fraud  and  embezzlement  are  but  rarely  resorted  to  by  the 
insane.  Indeed  most  offences  committed  by  the  insane  are 
due  to  violence  of  some  kind  irrespective  of  any  acquisitive 


THE   LEGAL   RELATIONS   OF   INSANITY        285 

tendencies,  whereas  fully  three-quarters  of  the  ordinary  criminal 
convictions  are  due  to  offences  pertaining  to  earning  a  living 
by  dishonest  means. 

Suicide  may  be  accidental,  impulsive,  or  intentional,  and  it 
may  occur  in  a  state  of  sanity  or  insanity.  The  practice  of 
coroner's  juries  is  to  regard  most  suicides  as  of  unsound  mind. 
Thereby  the  feelings  of  the  relatives  of  the  deceased  are  com- 
forted, and  religious  sentiments  at  the  funeral  obsequies  are  not 
disturbed.  The  law  of  self-preservation  varies  in  its  intensity 
in  different  countries,  and  the  act  is  not  always  committed 
through  motives  that  can  psychologically  be  regarded  as  insane. 
Attempts  at  suicide,  many  of  which  are  due  to  Alcohol,  are 
punishable,  but  if  insanity  is  manifest,  the  patient  is  usually 
handed  over  to  the  relatives  to  be  placed  under  care. 


CHAPTER  XXIII 
GENERAL    TREATMENT 

The  treatment  of  insanity  should  be  directed  towards 
removing  the  causes,  bodily  or  psychical,  of  mental  derange- 
ment, and  should  have  regard  not  only  to  the  brain  itself,  but 
also  to  the  whole  body  and  its  environment.  In  no  department 
of  Medicine  is  it  more  necessary  to  make  a  searching  inquiry 
into  the  exact  state  of  the  physical  health  of  the  patient, 
and  to  treat  any  morbid  diathesis  or  blood  condition  that  may 
exist.  Whatever  the  bodily  ailment,  be  it  the  cause  or  the 
effect  of  the  mental  breakdown,  it  wiU  reflect  itself  in  the 
mental  condition  of  the  patient,  and  therefore  the  first  con- 
sideration of  one  who  professes  to  treat  insane  patients  is 
to  correct  any  departure  from  ordinary  health.  Nevertheless, 
it  must  be  conceded  that  the  brain  does  not  depend  on  the  rest 
of  the  body  only,  and  that  the  healthy  vitality  of  its  mental 
functions  requires  suitable  psychic  stimuh  from  the  environ- 
ment, through  the  special  sense  organs.  This  applies,  of  course, 
to  all  diseases,  but  more  particularly  to  mental  disease,  and  there 
is  this  further  difference  between  them,  viz.,  that  certain 
social  and  legal  influences  come  into  play,  owing  to  the  dis- 
ordered conduct  which  a  patient  is  liable  to  exhibit.  Ex- 
perience has  shown,  accordingly,  that  mental  disease  is,  as  a 
rule,  best  dealt  with  in  special  establishments. 

The  general  treatment  of  insanity  may  be  regarded  from 
three  aspects,  viz.,  (1)  Preventive;  (2)  Curative;  and  (3)  the 
Care  of  the  Chronic  Insane  and  Mental  Defectives. 

1.  Preventive    Treatment 

Although  much  insanity  is  acquired  which  might  have 
been  prevented,  had  prudence  been  sho\\Ti  by  patients  in 
avoiding    Syphilis,   and    Alcoholic   or    other    excesses;    it   is 

286 


GENERAL   TREATMENT  287 

submitted  that  insanity,  for  which  there  is  no  adequate  ex- 
planation, does  occur  as  an  occasional  variation  in  healthy 
stocks,  but  that  nearly  half  the  total  number  of  cases  are 
due  to  inheritance. 

Without  doubt  many  neuropaths  might  have  been  saved 
from  actual  insanity,  if  precautions  had  been  taken  in  early 
life.  From  infancy  onwards,  many  of  them  exhibit  a  rest- 
less and  explosive  nervous  system,  which  shows  itself  in  sleep- 
lessness, excitability  and  ill-temper,  with  convulsions,  night 
terrors,  or  somnambulism.  Such  children  require  medical 
supervision  from  the  first,  especially  with  regard  to  their  diet, 
and  they  should  not  be  exposed  to  any  stimulating  influences. 
They  should  be  kept  in  the  open  air  as  much  as  possible — 
in  the  country  rather  than  in  towns,  and  they  should  be  trained 
to  regular  habits,  and  be  subjected  to  discipline  more  than 
ordinary  children.  Every  child  before  the  age  of  three  years 
should  be  made  to  lie  down  for  an  hour  or  two  before  noon 
for  the  purpose  of  inducing  sleep,  and  during  the  next  few 
years  should  be  made  to  rest  after  the  mid-day  meal.  Much 
depends  on  the  character  of  the  mother  or  nurse  in  the  proper 
upbringing  of  the  child.  Firmness  with  kindness  is  what  is 
to  be  desired,  and  the  child  must  be  trained  to  obedience, 
having  regard  to  its  ultimate  welfare,  and  must  not  be  spoilt 
by  weak-natured  parents.  Natural  affection,  therefore,  should 
not  be  allowed  to  develop  into  morbid  sentimentality.  An 
only  child  should  have  the  company  of  other  children  for  part 
of  the  day  to  suppress  its  selfish  nature,  and  to  promote  proper 
feelings  towards  others.  Respect  for  elders  should  be  incul- 
cated into  all  children.  It  is  to  be  remembered  thatthe  character 
of  a  child  is  in  process  of  formation  from  the  beginning,  and 
that  it  is  plastic  to  a  degree,  its  future  health  and  happiness 
depending  largely  on  the  moral  training  to  which  it  is  subjected. 
The  influence  of  good  or  bad  example  is  overpowering,  consider- 
ing how  imitative  a  child  is,  and  how  early  impressions  leave 
their  mark.  Proper  habits  of  thought,  feeling  and  behaviour 
should  be  instilled,  and  all  bad  tendencies  and  signs  of  disorder 
should  be  promptly  checked,  and  self-control  established.  The 
child  should  be  taught  from  its  own  observation,  and  should 
be  trained  to  use  its  hands  and  eyes,  rather  than  have  silly 
stories    poured    out    to    stimulate    its    infantile    imagination. 


288  MENTAL   DISEASES 

Gradually  its  powers  of  attention  and  application  should  be 
fostered,  but  there  should  be  no  cramming  of  the  memory, 
the  accumulation  of  knowledge  should  proceed  gradually  by 
the  method  of  association,  so  as  to  ensure  affirm  foundation 
for  the  future.  On  no  account  should  the  backward  child 
be  forced ;  it  matters  little  whether  it  is  late  in  walking 
and  talking,  as  this  is  even  better  than  premature  develop- 
ment, or  any  precociousness.  If  the  home  influences  are  good, 
there  is  little  need  for  schooling  until  seven  years  of  age, 
although  a  kindergarten  system  at  an  earlier  age  is  not  without 
advantage,  in  some  cases.  School-life  for  boys,  and  even  for 
girls,  is  on  the  whole  better  than  home  tuition,  and  it  becomes 
imperative,  if  the  parental  influences  are  injudicious  or  morbid. 

If  the  child  shows  any  dullness  or  backwardness  in  learning, 
it  may  be  advisable  to  have  special  tuition  separately  from 
ordinary  children  of  the  same  age,  but  should  it  be  defective, 
training  in  a  special  school  will  become  necessary.  The  too 
forward  child,  on  the  other  hand,  should  be  suppressed.  Slow 
but  steady  progress  is  better  than  brilliant  spurts,  and  the 
gaining  of  prizes  early  in  life  often  means  a  brain  that  blossoms 
too  soon,  only  to  fade  away  in  maturity.  It  should  be  borne 
in  mind  also  that  mental  and  bodily  development  frequently 
alternate,  and  that  lessons  should  be  relaxed  whilst  the  child 
is  growing  fast. 

The  question  of  sexual  problems  should  be  faced,  as  puberty 
approaches,  and  in  most  cases,  parents  should  be  more  frank 
in  imparting  judiciously  as  much  physiological  knowledge  as 
they  happen  to  possess.  It  should  be  realised  that  masturba- 
tion, especially  among  boys,  is  largely  due  to  evil  suggestion, 
and  that  a  little  home  chat  has  a  salutary  effect.  Again,  every 
mother  should  inform  her  daughter  at  the  first  onset  of  the 
menses,  and  rest  should  be  enjomed  at  these  periods.  Healthy 
outlets  for  activities  should  be  provided,  with  a  diversity  of 
interests  and  hobbies.  Young  people  should  be  made  as 
sociable  as  possible,  and  should  take  part  in  associated  outdoor 
recreations  and  sports,  which  are  conducive  to  self-control 
almost  as  much  as  other  educative  influences.  Unless  contra- 
indicated,  a  tepid  or  cold  bath  in  the  morning  tends  to  harden 
the  constitution ;  the  young  person  should  not  be  pampered, 
and  be   allowed  to  complain  of  a  hard  bed,  but  should  be 


GENERAL   TREATMEXT  289 

trained  to  habits  of  self-denial  and  endurance  of  discomfort. 
The  Boy  Scout  movement  and  School  Volunteering  are  helpful 
in  encouraging  discipUne  and  in  instilling  ideas  of  patriotism 
and  manliness.  Domestic  economy  should  be  included  in 
the  training  of  every  girl,  and  both  sexes  should  in  youth  be 
taught  to  swim.  Punctuality  is  a  virtue  to  be  preached  and 
practised.  There  should  be  no  sitting  up  late  at  night,  or 
getting  up  late  in  the  morning,  and  regularity  in  taking  meals, 
and  in  the  performance  of  the  natural  functions  should  be 
enforced.  Xeurotics  should  feed  up  and  become  as  fat  as 
possible.  All  fads  about  diet  should  be  discountenanced,  as 
well  as  all  taste  for  alcohol ;  tobacco-smoking  should  only 
be  allowed  after  maturity,  and  then  only  in  moderation. 
Introspective  young  people  should  be  taken  in  hand  at  once 
and  be  made  to  take  an  interest  in  outside  affairs.  The  nerv- 
ously disposed  should  be  kept  away  from  prolonged  Church 
services,  prayers  and  fasts,  and  religious  fanaticism  should 
be  promptly  stopped.  The  reading  of  unhealthy  novels  or  of 
other  doubtful  literature,  and  attendance  at  spectacles  likely 
to  excite  the  sexual  passions,  should  be  forbidden  to  young 
people. 

To  be  ambitious  is  no  evil,  even  to  the  nervous,  provided 
that  the  estimate  of  their  capabilities  is  not  misjudged.  Yet 
a  quiet  life  with  an  assured  income  is  better  for  such  persons, 
than  one  of  risk  in  seeking  fortunes  at  home  or  in  unhealthy 
climates.  Too  often  may  it  be  said  that  the  right  occupation 
in  life  has  not  befallen  a  person  predisposed  to  insanity.  There 
should  always  be  certain  holidays  at  regularly  stated  times, 
so  as  to  ensure  change  of  thought  and  scene,  as  a  means  of 
recreation. 

The  medical  profession  is  sometimes  consulted  as  to  the 
marriage  of  persons  predisposed  to  nervous  or  mental  disorders. 
Mostly  this  occurs  when  advice  is  of  little  avail,  as  in  matters 
of  love  the  reason  is  in  abeyance,  and  advice  is  only  asked  for  as 
a  matter  of  form.  This  question  has  to  be  considered  from  the 
point  of  view  of  both  partners,  and  from  that  of  any  possible 
progeny.  The  strain  of  celibacy  is  undoubted^  to  be  reckoned 
with  in  some  neurotic  men  and,  moreover,  the  advantage  of 
family  life  and  its  increased  interests  cannot  be  lost  sight  of, 
more  particularly  regarding  women.    A  neurotic  person  should 

u 


290  MENTAL   DISEASES 

not  form  a  union  with  one  similarly  tainted,  yet,  such 
couples  unwittingly  attract  one  another,  and  these  entangle- 
ments are  difficult  to  unravel.  When  such  marriages  occur, 
similar  sensitive  natures  are  prone  to  jar  on  each  other  in  the 
routine  of  domestic  life,  and  unhappiness  is  a  common  result. 
Long  engagements  are  bad  for  the  nervously  disposed,  especially 
for  girls  ;  yet  to  marry  in  haste,  on  indifferent  means  with  which 
to  support  a  home,  breeds  discontent,  and  produces  stress  not 
easily  to  be  glossed  over.  In  the  married  state,  during  any  phase 
of  insanity,  there  can  be  no  doubt  that  marital  relationship 
should  be  rigidly  debarred ;  and  in  remissions,  and  after 
convalescence,  a  word  of  warning  should  be  given,  both  to 
men  and  women,  to  exercise  prudence  and  temperance  in 
this  respect,  as  exhaustion  is  readily  induced  in  both  sexes, 
and  in  men  in  particular,  whilst  with  women  there  is  the  further 
risk  of  pregnancy.  A  patient  who  has  recovered  from  an 
attack  of  Confusional  insanity,  or  Intermittent  Mania  or  Melan- 
cholia, and  has  remained  well  for  at  least  two  years,  cannot  be 
entirely  debarred  from  matrimony,  but  the  other  contracting 
party  should  be  made  aware  of  the  previous  illness.  If  a  patient 
has  had  two  attacks,  the  medical  opinion  should  discourage 
any  matrimonial  alliance  at  all.  It  need  hardly  be  said  that 
persons  with  remissions  from  Delusional  insanity.  General 
Paralysis  or  Epileptic  insanity  should  not  be  allowed  to  marry 
upon  any  account. 

A  person  with  one  parent  insane  need  not  necessarily  be 
prevented  from  contracting  a  matrimonial  alliance  on  medical 
grounds ;  for  ethical  reasons,  however,  the  blemish  should 
not  be  concealed.  The  type  of  the  insanity  must  be  taken  into 
account,  and  the  general  family  stock  considered,  in  estimating 
the  risks.  It  might  here  be  mentioned  that  certain  advanced 
authorities,  including  Dr.  Robert  Jones  and  others,  urge  that 
chronic  insanity  should  be  legally  regarded  as  a  plea  for  divorce. 
This  opinion  does  not,  however,  receive  universal  approval, 
and  has  not,  therefore,  so  far  been  seriously  entertained  by  the 
public  at  large.  It  destroys  the  highest  ideals  of  the  matri- 
monial tie,  although  perhaps  tending  to  diminish  immorality 
and  illegitimacy.  Moreover,  the  idea  of  possible  divorce 
might  be  prejudicial  to  some  insane  patients. 

If  a  predisposed  person  is  threatened  with  an  attack  of 


GENERAL   TREATMENT  291 

insanity,  the  first  consideration  is  to  make  such  a  one  give  up 
his  or  her  occupation,  and  secondly,  sleep  and  change  of  scene 
must  be  procured.  This  frequently  prevents  a  recurrence 
in  one  who  has  had  an  attack  before.  Puerperal  patients  who 
have  recovered  should  not,  as  a  rule,  be  allowed  to  become 
pregnant  again,  the  risk  is  too  great,  and  all  exciting  causes  such 
as  alcohol,  or  strain  of  any  sort  should  be  removed.  At  the 
menopause  especially  should  care  be  exercised  in  the  manage- 
ment of  a  person  predisposed  to  insanity.  The  prevention 
of  insanity  on  Eugenic  principles  is  now  much  in  the  air,  but 
facts  are  still  wanting  to  justify  dogmatic  assertions  as  to 
matters  of  inheritance,  and  it  is  a  question  whether  the  con- 
tinuance of  the  human  species  through  individuals  of  the  average 
level  alone  would  be  ultimately  beneficial  to  the  race.  Cases 
of  arrested  mental  development,  and  degenerates,  should  cer- 
tainly not  be  allowed  to  propagate  their  species,  neither  should 
the  insane,  but  it  must  be  remembered  that  many  of  the  latter 
spring  from  stocks  from  which  the  talented  arise,  and  the 
wholesale  surrender  of  such  stocks  might  be  distinctly  pre- 
judicial to  the  human  species.  After  all,  it  may  be  said  in  a 
certain  sense  that  neurotics  are  the  salt  of  the  human  race. 


2.  Curative   Treatment 

The  best  chances  of  recovery  in  mental  disease  are 
obtained  when  a  patient  is  treated  early.  Too  often  do 
the  relatives  timidly  allow  a  case  to  go  from  bad  to  worse, 
so  that  valuable  time  is  lost.  This  is  done  in  the  hope  that 
the  patient's  liberty  will  not  need  to  be  interfered  with,  and 
that  the  brain  will  be  restored  by  its  own  devices.  Only 
in  the  milder  forms  of  mental  derangement  is  it  possible 
to  treat  a  ease  with  any  success  whilst  the  patient  continues 
his  usual  avocation.  This,  however,  happens  occasionally  in 
some  Melancholic  and  Psychasthenic  cases,  and  in  a  few  Alco- 
holic and  Drug  cases.  Generally  speaking,  it  is  necessary 
for  a  mental  patient  to  give  up  work,  and  to  undergo  a  regime 
of  supervision  in  which  a  nurse  or  trained  companion  plays 
an  important  part  in  carrying  out  the  orders  of  the  medical 
attendant. 

In  regard  to  a  poor  patient,  some  good  can  be  done  through 


292  MENTAL   DISEASES 

the  medium  of  the  mental  department  of  a  general  hospital, 
or  of  an  out-patient  department  of  an  asylum,  if  reliance  can 
be  placed  on  the  relatives  to  look  after  him,  but  in  many  instances 
it  is  best  to  call  in  the  relieving  officer,  so  that  adequate  attention 
can  be  obtained  at  the  union  infirmary  or  the  county  asylum. 
The  student  must  -realise  that  mental  disorders  invariably 
run  a  longer  course  than  most  other  disorders,  and  the  sooner 
a  poor  person  is  removed  from  his  home,  the  sooner  will  he 
recover,  if  he  is  a  curable  case.  Ratepayers  and  even  Justices 
are  frequently  tardy  in  recognising  this  fact. 

In  the  middle  and  upper  classes  different  courses  are  open. 
Sometimes  change  of  surroundmgs,  travelling  with  a  companion, 
or  a  visit  to  a  hydropathic  establishment  can  be  arranged,  and 
is  all  that  is  required  m  mild  cases,  so  long  as  there  is  no  evidence 
of  an  acute  attack  coming  on.  A  fresh  environment  with 
new  faces  frequently  submerges  morbid  ideas.  The  presence 
of  relatives,  indeed,  is  not  good  as  a  rule  ;  it  reminds  the  patient 
of  the  scenes  of  his  breakdown,  and  the  influence  of  strangers 
is,  therefore,  much  better.  In  more  pronounced  cases,  proper 
nursing  and  attention  can,  in  selected  cases,  be  obtained  in 
private  care,  yet  even  then  there  is  not  the  same  beneficent 
discipline  as  obtains  in  a  registered  hospital  or  private  asylum. 
If  certification  is  necessary,  institution  care  is  generally  the 
best  course  to  recommend  with  a  view  to  expediting  recovery, 
although  the  wishes  of  the  relatives  must  be  respected. 

Single  Care. — This  is  sometimes  carried  out  in  the 
patients  home  if  separate  apartments  can  be  procured,  but 
the  better  plan  is  to  rent  a  house,  or  to  secure  rooms,  in  country- 
lodgings,  or  in  a  nursing  home,  or  in  the  house  of  a  doctor  or 
layman.  All  of  these  methods  entail  more  or  less  expense, 
especially  if  the  case  necessitates  the  attendance  of  several 
nurses,  and  the  frequent  visits  of  the  practitioner. 

The  patient's  rooms  must  be  properly  adapted  if  the  case 
is  acute  or  suicidal,  and  for  safety,  they  should  preferably  be 
on  the  groimd  floor.  Shutters  should  be  used  when  necessary, 
and  each  window  may  require  protection  by  placing  furniture 
before  it,  or  preferably  it  should  be  blocked  by  a  screw  in  the 
sash,  so  that  the  openings  at  the  top  and  bottom  do  not  exceed 
six  inches.  Keys  and  bolts  should  be  removed  from  the  doors. 
Fireplaces   should   be   guarded,   projecting   hooks   should   be 


GENERAL   TREATMENT  293 

removed,  and  no  weapons  or  things  likely  to  be  harmful,  such  as 
pokers,  knives,  scissors,  hat -pins,  cords,  missiles,  matches,  medi- 
cines and  poisons,  should  be  left  about.  But  little  furniture, 
and  as  few  ornaments  as  possible  should  be  allowed  in  the  bed- 
room of  a  destructive  patient,  and  it  may  be  advisable  to  have 
the  mattress  on  the  floor  instead  of  on  a  bed.  A  commode 
should  be  provided,  or  if  the  patient  is  fit  to  use  the  closet, 
the  bolt  must  be  removed.  In  the  case  of  a  patient  who  tears 
his  or  her  clothing,  special  strong  nightdresses  and  blankets 
may  be  necessary,  while  in  the  case  of  a  patient  with  defective 
habits,  the  mattress  should  be  protected  by  a  mackintosh 
covered  by  a  small  blanket,  and  a  drawsheet  should  be  used 
over  the  ordinary  sheet.  A  rubber  urinal  may  be  advisable 
in  the  room  instead  of  a  chamber  made  of  china.  There  should 
be  a  suitable  garden  for  exercise,  taking  care  that  it  contains 
no  unprotected  wells  or  ponds. 

Private  care  may  be  sanctioned  by  the  practitioner  without 
certification  in  the  patient's  own  house,  or  that  of  one  of  his 
relatives,  provided  no  charge  be  made  for  maintenance,  and  no 
undue  restraint  be  exercised.  The  nurses,  male  or  female, 
should  be  properly  trained  for  mental  cases  with  asylum  rather 
than,  or  in  addition  to,  ordinary  hospital  experience.  Notes 
and  charts  should  be  kept  as  to  sleep  and  a  daily  record  of 
the  diet  and  treatment,  and  of  the  weight  from  time  to 
time.  The  nursing  staff  should  be  sufficient,  so  that  relief 
can  be  arranged  for  day  and  night  duty.  Nominally  the 
nurses  act  under  the  instructions  of  the  practitioner,  but 
they  should  be  regarded  as  the  paid  servants  of  the  relatives 
of  the  patient,  as  in  other  diseases.  The  relatives  must  be 
held  responsible  for  the  treatment,  apart  from  medical  considera- 
tions, and  sometimes  it  is  advisable  for  the  practitioner  to 
obtain  from  them  a  letter  of  indemnity  from  any  possible  legal 
risks.  The  same  conditions  apply  equally  to  a  patient  in  a 
house  that  has  been  rented,  or  in  lodgings,  provided  the  respon- 
sible relative  in  authority  resides  there  also.  Should,  however, 
the  presence  of  a  relative  be  impossible,  unless  the  case  be  a 
mild  or  border-line  one,  the  law  must  be  complied  with.  This 
applies  also  when  a  patient  is  in  a  nursing  home,  or  in  the  house 
of  a  doctor  or  layman,  at  a  fixed  charge.  If  certifiably  insane, 
the  requisite  documents    for  single  care    must  be  obtained; 


294  MENTAL   DISEASES 

or  the  patient  must  be  taken  home,  or  better  still,  be  removed 
to  an  institution. 

The  cases  that  can  be  sanctioned  for  single  or  private  care  are 
Puerperal,  Alcoholic  and  other  acute  cases  that  are  likely  to  have 
a  short  duration,  or  those  likely  to  end  fatally  in  a  short  space 
of  time,  some  harmless  Senile  cases,  or  mild  Dements,  and  some 
Adolescent  cases,  but  it  must  be  pointed  out  that  their  means 
must  be  sufficient.  Unsuitable  cases  are  chronic  noisy  and 
destructive  patients,  those  with  defective  habits,  or  who  are 
morbidly  erotic,  those  who  are  very  muscular  and  overpowering, 
and  those  with  pronounced  homicidal  or  suicidal  tendencies, 
or  who  continuously  refuse  food.  Most  Paranoiacs,  General 
Paralytics,  and  insane  Epileptics  are  unfit  for  single  care. 

In  the  present  state  of  public  opinion,  although  institutions 
are  more  in  favour  than  they  were,  there  is  still  a  stigma 
attached  to  certification  which  is  wholly  unj  ustifiable,  and  which 
the  profession  should  do  its  utmost  to  combat.  Certification, 
however,  does  incapacitate  patients  from  signing  cheques 
and  legal  documents,  and  frequently  breaks  partnerships  and 
other  agreements,  so  that  in  suitable  cases  the  patient  and  the 
relatives  are  better  pleased  if  recovery  can  be  effected  in 
uncertified  private  care.  It  is,  moreover,  unwise  to  press  for 
certificates  when  the  relatives  are  very  averse,  but  the  prac- 
titioner should  never  lend  his  support  to  any  infringement 
of  the  law,  and  he  should  place  the  honour  of  his  profession 
and  the  interests  of  his  patient  before  all  else. 

It  must  be  acknowledged  that  private  care  is  fraught  with 
more  risks  than  institution  care.  Moreover,  there  is  apt  to 
be  an  inefficient  medical  supervision  over  the  patient  and  the 
staff.  The  relatives  are  rarely  helpful  and  sometimes  they 
are  interfering.  In  some  single-care  cases  there  appears  to  be  a 
want  of  emulation,  and  patients  do  not  try  to  get  well.  In 
other  cases  the  system  becomes  monotonous  after  a  time.  A 
patient  feels  unable  to  ventilate  his  grievances  outside  his 
immediate  sphere.  Moreover,  the  association  with  insane 
persons  is  apparently  sometimes  even  better  than  that  with 
sane  persons  to  promote  recovery,  whilst  the  impression  caused 
by  other  patients  leaving  an  institution  when  they  get  well, 
is  distinctly  beneficial.  In  private  care  the  idea  that  the  whole 
effort    of   a    household    is    directed    towards    one    individual. 


GENERAL   TREATMENT  295 

serves  occasionally  to  foster  just  those  selfish  and  anti-social 
evils  which  are  at  the  root  of  the  patient's  disorder.  Many 
cases,  however,  begin  with  private-care  treatment,  and  if  it 
does  not  answer,  the  patient  is  moved  later  to  an  institution. 
Similarly,  some  cases  that  have  passed  through  acute  attacks 
in  institutions  are  transferred  to  private  care  if  they  do  not 
recover,  provided  they  are  quiet  and  harmless. 

Institution  Care. — The  different  kinds  of  institutions  have 
already  been  referred  to  {vide  p.  272).  The  vast  majority  of 
patients  therein  are  certified,  i.  e.  detained  under  care  and 
treatment.  In  the  private  class,  however,  voluntary  patients 
can  also  be  received,  except  in  public  asylums  (rate-supported 
asylums).  It  has  been  suggested  that  voluntary  treatment 
should  also  apply  to  a  pauper.  This,  at  present,  the  law  does 
not  provide  for. 

Institution,  asylum,  or  hospital  care  is  practically  the  only 
form  of  treatment  for  a  pauper  patient,  as  home  care  is  almost 
out  of  the  question  except  at  the  outset.  A  pauper  patient 
is,  therefore,  sent  to  the  nearest  public  asylum  (possibly  to  the 
infirmary  first)  and  is  later  transferred  to  the  county  to  which 
he  is  chargeable.  The  British  asylums  as  such,  are  second  to 
none  in  any  country  in  the  world.  The  buildings  are  com- 
modious, they  have  large  recreation  and  dining  halls,  employ- 
ment and  amusements  are  provided,  their  farms  are  good, 
their  grounds  attractive,  and  the  discipline  and  morale  are 
satisfactory.  On  the  score  of  economy,  and  to  meet  the  press 
of  accommodation,  asylums  unfortunately  have  in  later  years 
been  enlarged  to  an  inordinate  size,  and  the  medical  staff  has 
not  been  increased  in  proportion.  Still,  the  medical  spirit  is 
on  the  whole  maintained,  and  in  many  instances  it  reaches  a 
high  standard  of  excellence  for  original  work,  and  the  treatment 
of  patients  is  benefited  thereby.  In  London,  through  the 
munificence  of  Dr.  Maudsley,  a  mental  hospital  is  shortly  to 
be  opened  as  a  reception-house  for  acute  cases  of  the  London 
County.  It  will  have  a  pathological  laboratory  attached, 
which  will  greatly  help  in  the  scientific  investigation  and 
teaching  of  insanity,  and  also  afford  opportunities  for  the 
most  recent  methods  of  treatment. 

In  the  registered  hospitals  the  patiejits  are  of  the  private 
and  often  of  the  upper  class ;    in  some  of  them,  special  villas 


296  MENTAL   DISEASES 

are  provided,  and  also  country  or  sea-side  branches.  Private 
asylums  are  mostly  smaller  in  size,  and  form  a  medium  between 
registered  hospitals  and  single  private  care.  Both  in  registered 
hospitals  and  in  private  asylums,  more  individual  medical 
attention  is  able  to  be  given  to  patients  than  is  possible  in 
public  asylums.  The  medical  staff  is  numerically  stronger, 
supervision  is  closer,  companions  are  engaged  in  addition  to 
the  nurses,  recreations  and  amusements  are  more  in  evidence, 
excursions  are  provided,  sea-side  visits  are  arranged,  and  every 
endeavour  is  made  to  promote  the  welfare  of  patients.  All 
are  under  official  inspection,  and  there  is  little  to  choose  between 
a  registered  hospital  or  private  asylum  except  as  regards  size. 
Some  patients  do  better  in  a  large  than  in  a  small  institution, 
and  vice  versa.  From  the  point  of  view  of  the  patient,  or  his 
relatives,  the  element  of  profit  scarcely  needs  much  considera- 
tion, whether  such  be  spent  on  philanthropy  by  a  committee, 
or  in  raising  the  salaries  of  the  staff,  or  goes  to  reward  individual 
enterprise.  There  is  perhaps  more  privacy  in  a  private  asylum, 
and  greater  facilities  for  the  visits  of  relatives  than  in  a  regis- 
tered hospital.  A  quarterly  payment  in  advance  is  generally 
expected  by  the  committee  of  a  registered  hospital,  which 
is  not  usual  in  a  private  asylum. 

What  is  urgently  wanted  at  present  is  a  certain  number  of 
small  mental  hospitals  properly  endowed,  in  various  parts  of 
the  country,  so  that  private  patients  of  the  needy  cultured  class 
can  be  received  at  low  rates,  instead  of  being  sent  to  public 
asylums,  the  existing  registered  hospitals  not  being  able  to 
afford  to  do  more  than  a  certain  amount  of  charitable  work. 

Unlike  pauper  patients,  who  are  always  in  the  control  of 
an  asylum  committee,  private  patients  are  in  the  hands  of 
their  respective  petitioners,  and  they  can  be  removed  at  any 
time,  whether  improved  or  not,  so  that  no  fear  of  undue  deten- 
tion by  the  institution  need  be  feared.  The  only  veto,  which, 
however,  is  only  a  temporary  one,  so  far  as  the  medical  officer 
is  concerned,  and  is  scarcely  ever  exercised,  is  in  the  case  of  an 
actively  suicidal  or  dangerous  patient  who  may  be  considered 
unfit  to  be  at  large,  and  yet  whose  relatives  may  be  anxious 
for  his  discharge.  On  the  other  hand,  should  a  private  patient 
desire  his  discharge  and  the  petitioner  be  unwillmg  to  consent, 
ample  safeguards  exist  in  a  doubtful  case.   A  patient  can^ always 


GENERAL   TREATMENT  297 

have  a  private  interview  with  the  visiting  Commissioners,  and 
can  correspond  with  them  and  with  certain  other  authorities. 
Besides,  there  is  the  appeal  to  the  medical  officer,  whose  duty  it 
is  to  send  notice  to  the  petitioner  when  a  patient  has  recovered. 
A  patient  can  then  leave  at  the  end  of  seven  days,  if  his  previous 
discharge  is  not  authorised  by  the  petitioner. 

In  the  selection  of  an  institution  for  private  patients  the 
question  of  means  largely  enters,  the  terms  varying  from  about 
one  to  twenty  guineas  per  week,  according  to  the  accommoda- 
tion and  attention  required.  It  should  not  be  too  near  the 
patient's  home,  so  as  not  to  interfere  with  his  walks  or  drives 
outside,  or  be  too  far  for  the  relatives  to  visit.  Practically  all 
are  now  well  managed,  patients  frequently  return  voluntarily 
as  boarders  when  a  relapse  occurs,  and  some  recovered  cases 
elect  to  remain  as  such,  which  speaks  well  for  the  treatment 
obtained.  Most  are  in  rural  districts,  with  easy  access  to 
towns,  and  it  matters  httle,  as  regards  the  course  of  insanity, 
whether  a  high  or  a  low  ground,  or  an  inland  resort  or  not,  be 
chosen,  although  some  influence  on  the  bodily  health  may  be 
achieved  by  climatic  means.  As  much  liberty  and  parole  is 
given  as  is  consistent  with  the  patient's  safety  and  welfare, 
and  the  open-door  system  has  almost  exceeded  its  limit.  A 
convalescent  patient  leaving  an  institution  generally  does  so 
on  probation,  a  private  patient  usually  having  some  inter- 
mediate change  before  returning  to  his  home,  or  to  his  ordinary 
occupation. 

The  Rest  Cure. — Separation  from  those  influences  and 
surroundings  which  obtained  when  the  mental  attack  developed, 
is  the  first  desideratum  for  successful  treatment.  The  com- 
panionship of  relatives  of  an  insane  patient,  as  has  already 
been  pointed  out,  invariably  does  more  harm  than  good, 
moreover,  the  effect  of  the  patient  upon  them  is  deleterious. 
As  in  other  disorders,  so  in  mental  diseases,  rest  is  to  be  en- 
joined in  the  acute  stage,  and,  as  has  been  mentioned  before, 
the  earlier  a  patient  is  placed  under  treatment  the  more  hopeful 
is  the  result.  Especially  is  rest  indicated  for  Exhaustion  and 
Stuporous  cases,  Acute  Melancholiacs,  and  for  most  Maniacs 
in  the  early  stages.  This  treatment  is  practically  only  contra- 
indicated  in  Neurasthenics,  who  are  prone  to  form  the  bed 
habit,  and  in  some   abnormally  introspective  cases,   and  in 


298  MENTAL   DISEASES 

pronounced  masturbators.  The  patient  should  be  put  to  bed 
and  carefully  examined,  and  be  placed  in  the  charge  of  skilled 
nurses.  He  should  be  weighed,  and  a  weekly  chart  of  the 
weight  should  be  kept.  Cases  with  oedema  of  the  legs  should 
be  kept  in  bed  continuously  at  first.  Emaciated  patients  may 
require  the  use  of  a  water  bed  or  air  cushions.  Other  cases 
later  on  may  be  allowed  to  sit  up  for  a  while  in  the  afternoons. 
Open-air  treatment  should  be  adopted  as  much  as  possible. 
Some  cases  benefit  by  occasional  light  walking  exercise  in  the 
garden,  if  their  pent-up  energy  requires  it.  This  is  better  than 
massage,  frictions,  or  artificial  passive  exercises  of  any  sort. 
Thereby  much  restlessness  and  purposeless  action,  destructive- 
ness,  and  noisiness  may  be  averted.  In  spite  of  all  that  has 
been  said  in  its  favour,  continuous  bed-treatment  does  not  suit 
all  cases  of  recent  insanity.  Moreover  narcotic  drugs  are  then 
liable  to  be  abused,  even  in  institutions.  Much  tact  must  be 
exercised  in  the  management  of  turbulent  patients.  There 
should  be  no  struggling  with  a  patient  single-handed,  and  the 
nursing  staff  should  be  adequate.  Seclusion  may  at  times  be 
necessary  in  very  violent  patients ;  if  resorted  to  in  the  day 
time  it  must  be  recorded.  For  this  purpose,  a  padded  room 
has  less  risks  than  an  ordinary  room  in  subduing  frenzied 
excitement,  and  such  cases  often  do  better  there  than  when 
they  are  forcibly  controlled  by  attendants,  or  restrained  by 
chemicals.  Mechanical  restraint^ — in  the  form  of  a  strait-jacket 
or  padded  gloves — is  only  rarely  necessary  in  some  patients 
who  are  extremely  violent  and  are  not  safe  to  be  secluded,  or 
else  are  very  suicidal,  or  who  require  it  for  surgical  treatment. 
It  must  be  entered  in  the  official  books. 

Letters  from  and  to  relatives  should  be  as  few  as  possible 
during  acute  insanity.  Likewise,  it  is  best  for  them  not  to 
visit  until  the  patient  is  better.  As  further  improvement 
occurs,  more  exercise  should  be  allowed,  a  good  sharp  walk 
being  best  for  most  cases,  and  later,  outdoor  games  and  re- 
creations should  be  encouraged. 

Baths. ^This  form  of  treatment  is  a  valuable  adjunct  to 
the  rest  cure.  Excitement  is  in  many  cases  subdued  by  an 
occasional  tepid  bath,  but  more  often  by  prolonged  immersion  in 
a  warm  bath  (95°  F.)  lasting  from  half  an  hour  to  six  hours  or 
longer.    In  some  instances  a  cold  plunge  bath  may  be  ordered,  in 


GENERAL   TREATMENT  299 

which  case  its  action  is  more  pronounced ;  a  spray  or  shower 
may  also  be  used,  with  alternate  hot  and  cold  douches  to  the  head 
and  spine.  Never  under  any  circumstances  should  a  bath  be 
given  as  any  form  of  punishment  or  as  a  surprise.  Cold  com- 
presses or  ice-bags  to  the  head  are  efficacious  in  delirious  cases. 
A  sitz  bath  or  a  foot  bath  may  be  indicated  in  certain  cases, 
and  in  others,  daily  sponging  of  the  body  should  be  adopted  for 
cleanliness  and,  if  need  be,  to  reduce  temperature.  The  wet  pack 
is  now  rarely  used,  viz.,  wrapping  a  patient  in  a  sheet  wrung  out 
of  cold  or  hot  water  and  enveloping  him  in  blankets  for  half 
an  hour  or  more ;  it  induces  perspiration,  and  it  certainly  has 
a  calming  influence,  but  in  the  treatment  of  a  certified  insane 
person  it  is  regarded  as  mechanical  restraint.  Baths  medicated 
by  mustard,  sea  salt,  etc.,  are  but  rarely  necessary.  Hot-air 
baths,  light  baths,  and  sun  baths  are  occasionally  of  service. 

Electricity. — This  is  best  applied  as  the  interrupted  current 
passed  from  the  light  mains  by  means  of  a  transformer  through 
electrodes  at  each  end  of  a  warm  bath.  It  is  undoubtedly 
refreshing,  but  acts  chiefly  by  suggestion  as  a  beneficial  agent. 
The  faradic  battery  is  useful  in  some  cases  in  keeping  the 
muscles  in  good  tone  ;  the  galvanic,  static,  and  high  frequency 
currents  do  some  good  in  neuralgia  and  in  certain  kinds  of 
headache,  and  in  the  form  of  the  electric  brush,  the  faradic 
current  has  at  times  a  good  effect  in  Hysteria. 

Diet. — This  requires  careful  consideration.  In  acute  cases, 
as  a  rule,  the  feeding-up  principle  should  be  adopted,  with 
easily  digested  fiuid  diet — a  pint  of  warm  milk  with  two  eggs 
given  every  three  or  four  hours,  with  an  intermission  twice  a 
day  for  the  ingestion  of  a  pint  of  beef  tea  or  chicken  broth  with 
some  fine  breadcrumbs  or  toast  softened  therein,  or  of  a  pint  of 
arrowroot,  Benger's  food,  Robinson's  groats,  or  if  need  be,  of  a 
cup  of  ovaltine,  plasmon,  or  sanatogen.  If  the  patient  dislikes 
milk  it  may  be  flavoured  with  weak  tea,  or  mixed  with  some 
other  agent  such  as  barley  water,  lime  water,  or  aerated 
water.  Some  patients,  especially  old  people,  do  better  on  small 
quantities  often  repeated,  such  as  raw  eggs,  etc.  It  is  of  no 
use  overloading  a  weak  digestive  system  at  the  risk  of  caus- 
ing vomiting,  diarrhoea,  and  constipation.  When  vomiting  is 
persistent,  albumen  water  may  be  given  or  peptonising  agents 
may  be  required.     As  the  tongue  and  digestion  improve,  solid 


300  MENTAL   DISEASES 

food  may  be  given  gradually,  at  first  finely  minced-up  vegetables 
with  gravy,  and  then  meat.  Any  diathesis  present,  such 
as  Gout  or  Rheumatism,  must  be  dietetically  treated.  The 
liquid  food  may  be  given  in  a  strong  china  feeding-cup,  or  else 
in  a  horn  cup,  if  the  patient  be  inclined  to  violence.  Sufficient 
time  should  be  given  for  meals,  and  no  bolting  of  food  allowed, 
so  that  risks  of  choking  may  be  averted.  When  the  patient 
feeds  himself,  spoons  and  forks  only  should  be  allowed  at  first. 
In  private  patients  silver  knives  should  be  used  for  safety, 
instead  of  steel  ones,  until  all  impulsive  symptoms  have  dis- 
appeared. 

Alcohol  as  a  beverage  is  rarely  to  be  given  in  insanity. 
In  Exhaustion  and  Anaemic  cases,  however,  half  a  pint  of  stout, 
or  a  glass  of  port  wine,  or  of  champagne,  once  or  twice  a  day 
is  frequently  beneficial,  and  in  some  cases  is  most  necessary. 
So  also  in  Senile  cases  a  peg  of  whisky,  or  brandy  in  water 
or  milk  assists  the  cerebral  circulation  and  calms  restless 
irritability.  Hot  toddy  at  night,  moreover,  helps  to  procure 
sleep.  In  those  predisposed  to  Alcoholism,  stimulants  should, 
of  course,  be  rigidly  prohibited.  The  acutely  insane  should  be 
encouraged  to  drink  as  much  fluid  as  they  will,  to  set  the 
eliminatory  organs  in  full  working  order. 

Refusal  of  Food. — The  diet  of  the  insane  should  be  served 
up  so  as  to  entice  those  with  poor  appetites.  Frequently  a  patient 
can  be  induced  to  take  his  meals  with  gentle  persuasion  and 
coaxing.  Many  do  not  take  enough  from  failure  of  volition. 
For  most  of  these  cases,  feeding  by  the  nurses  is  necessary,  with 
ordinary  food  properly  cut  up,  and  if  a  glass  is  held  up  to  the 
mouth,  they  will  frequently  drink.  Some  patients,  who  resist 
but  feebly,  will  allow  themselves  to  be  fed  with  a  spoon  or  a 
feeding-cup.  Or  they  will  sometimes  swallow  food  by  means 
of  a  funnel  with  a  short  tube  passed  through  the  nose  to  the 
pharynx.  If,  however,  a  patient  is  persistently  taking  too 
little  food,  or  refuses  it  altogether,  it  is  necessary  to  have 
recourse  to  forcible  feeding.  This  contingency  occurs  more 
frequently  in  private  patients  than  in  paupers.  Care  should 
be  exercised  in  ascertaining  whether  there  is  local  disease  to 
account  for  the  refusal  of  food,  and  it  is  necessary  to  be  cautious 
in  feeding  such  cases. 

Except    as   a   temporary  measure  when   there   is   gastric 


GENERAL   TREATMENT  301 

disorder  or  persistent  vomiting,  it  is  seldom  much  good  to 
resort  to  rectal  feeding,  as  enough  nourishment  and  fluid 
cannot  be  satisfactorily  given  in  that  manner  in  cases  of 
insanity.  Sufficient  nurses  should  be  available  for  forcible 
feeding.  A  sheet  held  over  the  patient  for  that  purpose  is 
not  regarded  technically  as  mechanical  restraint ;  care  should 
be  taken  that  the  chest  movements  are  not  impeded,  and  that 
the  patient's  ears  are  not  bruised.  Generally  speaking,  in 
difficult  cases,  it  is  best  to  feed  a  patient  lying  on  a  mattress, 
with  the  head  slightly  inclined  forwards,  but  the  sitting  posture 
frequently  answers  well.  One  nurse's  attention  should  be 
directed  to  holding  the  head  firm,  and  in  oesophageal  feeding 
to  keeping  the  gag  in  position.  Besides  the  gag,  a  basin  should 
be  provided,  a  rubber  tube  affixed  to  a  funnel,  a  small  jug  of 
water,  some  glycerine  for  lubrication,  and,  of  course,  the  food 
to  be  administered,  and  any  medicines  to  be  added. 

The  CEsophageal  Tube. — The  stomach  pump  is  never 
used  now,  but  a  soft  rubber  tube  (No.  24  to  28),  long  enough  to 
pass  eighteen  inches  from  the  teeth.  Eor  this  purpose,  a  gag 
(protected  by  rubber),  of  which  many  patterns  are  made,  must 
be  used.  Care  should  be  taken  in  separating  the  teeth  not  to 
produce  any  injury,  and  the  gag  must  not  be  allowed  to  slip. 
In  women  the  teeth  are  more  brittle,  and  therefore,  whenever 
possible,  it  is  better  to  use  the  nasal  tube.  The  tube,  warmed 
and  lubricated,  may  be  guided  past  the  epiglottis  by  the  fore- 
finger, and  if  the  pharyngeal  reflex  does  not  occur,  a  little  water 
should  be  introduced  through  the  tube  as  a  stimulus,  which 
usually  answers  well ;  when  the  patient  swallows,  the  tube 
should  be  gently  but  quickly  passed  downwards.  Should  it 
enter  the  larynx,  coughing  generally  occurs.  Its  entry  into  the 
stomach  is  usually  accompanied  by  the  escape  of  gases,  and 
it  is  as  well  not  to  pass  it  farther  for  fear  of  setting  up  vomiting. 

The  food  should  not  be  cold,  nor  too  hot ;  and  if  powders, 
medicines  or  stimulants  are  administered,  they  should  be 
gradually  poured  into  the  funnel  with  the  food.  Although  food 
of  thicker  consistence  can  be  given,  it  is  better  to  give  eggs  and 
milk,  soups,  arrowroot,  etc.,  two  pints  two  or  three  times  a  day 
being  the  usual  quantity,  and  in  prolonged  cases,  orange  juice 
should  be  added  from  time  to  time.  If  food  is  regurgitated, 
the  gag  and   tube  should  be  instantly  removed,  and  when 


302  MENTAL   DISEASES 

withdrawn  it  should  be  compressed  to  prevent  any  contents 
running  out  or  being  inhaled  ;  when  the  vomiting  has  ceased, 
the  tube  may  be  passed  again. 

The  Nasal  Tube.— A  soft  rubber  tube  (No.  11  to  13)  of 
similar  length  to  an  oesophageal  one  is  used,  with  a  funnel  and 
the  other  requisites. already  mentioned,  with  the  exception  of 
a  gag.  Usually  the  nasal  septum  is  deflected  so  that  the  tube 
passes  more  easily  down  one  nostril  than  the  other.  After 
introducing  it  along  the  floor  of  the  nose,  as  far  as  the  pharynx, 
the  patient  should  be  asked  to  swallow ;  if  no  reflex  occurs, 
a  little  water  should  be  poured  into  the  tube,  which  device 
is  usually  effectual.  If  the  tube  curls  into  the  mouth,  it  must 
be  withdrawn  a  little  and  another  attempt  be  made.  If  it 
passes  into  the  larynx  and  trachea,  there  is  coughing,  unless 
the  pharynx  and  larynx  are  anaesthetic,  and  on  listening  the 
inspired  and  expired  air  can  be  heard.  To  be  sure  it  is  in  the 
stomach  or  oesophagus,  and  that  the  lumen  is  open,  a  httle 
water  may  be  introduced  before  filling  up  the  funnel  with  the 
food.  A  pint  or  more  of  egg  and  milk,  etc.  can  be  given  three 
times  a  day.  When  the  tube  is  withdrawn,  it  should  be 
pinched  to  obviate  any  escape  of  food  which  might  be  inhaled 
into  the  trachea. 

There  is  really  not  much  to  choose  between  the  oesophageal 
and  nasal  methods  of  feeding.  It  depends  largely  upon  the 
case  as  to  which  method  should  be  adopted.  The  oesophageal 
tube  takes  shorter  time,  more  food  can  be  given,  and  semi-solids 
can  be  introduced,  but  it  requires  more  nurses  and  the  use  of 
a  gag,  and  regurgitation  is  a  little  more  easy  to  produce.  The 
nasal  tube  is  more  apt  to  become  blocked,  and  if  continuously 
used,  it  may  cause  irritation  of  the  nasal  mucous  membranes. 
In  aU  artificial  feeding  the  mouth  should  be  cleansed  with 
mild  antiseptic  solutions  each  day,  and  an  occasional  wash-out 
of  the  stomach  is  also  beneficial.  Inhalation  of  regurgitated 
food  into  the  lungs  produces  Pneumonia,  but  this  seldom 
happens  from  tube  feeding  in  experienced  hands. 

The  Bowels  and  Bladder. — Regular  habits  in  voiding 
the  excreta  should  be  established  as  far  as  possible  in  all  insane 
patients.  Some  delusional  cases  do  all  they  can  to  prevent  an 
evacuation,  whilst  others  constantly  seek  unnecessary  relief. 
The  excreta  should  be  inspected  in  cases  with  visceral  delusions, 


GENERAL   TREATMENT  303 

or  with  Colitis,  and  for  such  examination  a  bedpan  or  night- 
commode  is  requisite.  Constipation  is  very  usual  in  insanity, 
and  it  requires  similar  treatment  to  that  adopted  in  ordinary 
persons,  viz.  laxative  diet,  fresh  fruit,  morning  saline  draughts, 
Paraffin,  Cascara,  Liquorice,  Aloin,  Rhubarb,  Senna,  Enemas, 
etc.  Only  occasionally  should  Calomel,  Colocynth,  or  other 
strong  purge  be  given,  and,  as  a  rule,  a  larger  dose  is  necessary 
than  in  sane  persons.  The  state  of  the  bladder  frequently 
requires  attention,  and  in  every  case  the  urine  should  be  tested. 
Retention,  with  or  without  overflow,  is  common  in  Prostatic 
cases.  Tabetics,  General  Paralytics,  and  in  Hysteria  and  Stupor ; 
it  may  require  a  hot  bath,  or  a  rubber  catheter  for  its  treatment, 
whilst  ordinary  incontinence  may  often  be  corrected  by  tactful 
management  of  the  nurse.  All  catheterisation  must  be  carried 
out  with  strict  antiseptic  precautions,  and  any  trace  of  Cystitis 
should  receive  treatment  by  washing  out,  or  by  the  administra- 
tion of  Urotropin.  The  fact  that  patients  become  wet  and 
dirty  is  largely  due  to  defective  nursing,  but,  despite  all  care, 
some  cases  require  a  mackintosh  and  draw  sheet  at  night, 
and  destructive  cases  need  a  rubber  urinal.  Bedridden  cases 
must  be  kept  dry,  the  skin  of  the  buttocks  must  be  cleansed 
frequently,  and  the  position  changed  at  regular  intervals. 
Local  rubbings  with  a  solution  of  zinc  salts  and  spirit  do  good. 
Care  should  be  taken  that  bedsores  do  not  occur. 

Masturbation. — This  perversion  of  the  sexual  instinct 
sometimes  needs  special  treatment,  for  its  practice  invariably 
retards  recovery.  It  is  usually  associated  with  weak  bodily 
health,  and  feeding  up  with  fattening  rather  than  nitrogenous 
diet  tends  to  lessen  the  habit.  The  bowels  should  be  kept 
open  regularly,  and  the  blood-pressure  should  be  kept  down. 
Cold  baths  and  exercise  are  corrective,  and  close  supervision 
with  wholesome  moral  influence,  is  best  to  stop  the  evil.  The 
patient's  interest  in  open-air  pursuits  should  be  aroused. 
Local  applications,  such  as  blistering,  or  operative  measures, 
are  of  no  avail,  and  mechanical  devices,  which  keep  the  patient's 
mind  centred  on  the  evil,  are  unpractical  and  useless.  A  dram 
of  the  liquid  extract  of  Salix  Nigra,  or  of  Piscidia  Erythrina, 
with  Bromide  and  Camphor  water  in  the  evening,  is  sometimes 
beneficial,  together  with  a  nervine  tonic  in  the  daytime.  This 
vice  is  mostly  associated  with  nervous  instability^. 


304  MENTAL   DISEASES 

Suicidal  Intentions. — These  can  best  be  prevented  by 
continuous  watchfulness  on  the  part  of  the  nurses.     A  card  is 
usually  issued  which  is  signed  by  them,  and  is  in  the  keeping 
of  the  nurse  in  charge ;   it  has  directions  that  the  patient  must 
always  be  kept  under  observation.     For  this  purpose,  he  must 
be  followed  to  the  lavatory,  and  no  medicines  or  poisons  should 
be  left  about.     All  possible  dangers  must  be  guarded  against, 
such  as  staircases,  windows,  fireplaces,  etc.,  and  the  nurse  should 
take  care  to  see  the  patient  does  not  pick  up  pieces  of  glass,  or 
stones,  which  might  be  swallowed,  or  be  otherwise  utilised  for 
self -injury,  and  does  not  have  access  to  knives,  scissors,  pins, 
matches,  etc.    He  should  be  searched  at  night,  and  he  should  not 
have  possession  of  a  handkerchief  or  any  cords  or  tapes  belong- 
ing to  night  clothing,  and  he  should  not  be  allowed  to  cover  up 
his  face  under  the  bedclothes.     Generally  speaking,  it  is  best  to 
be  open  and  to  talk  about  any  suicidal  tendency,  and  as  the 
patient  improves,  and  the  impulse  disappears,  to  gain  his  confi- 
dence with  a  view  of  ascertaining  how  far  he  can  be  trusted  and 
of  obtaining  a  promise  that  he  will  not  injure  himself.     No  risk 
should  be  run  by  allowing  a  patient  out  for  country  waU?;s  whilst 
actively  suicidal,  for  fear  of  injury  from  motors,  trains,  drowning, 
or  of  the  possibility  of  escape.     It  is  at  the  beginning  of  mental 
disorder,  before  volition  is  paralysed,  and  as  improvement  from 
an  attack  sets  in,  that  most  anxiety  is  felt  as  to  a  suicidal 
patient. 

Insomnia. — In  most  recent  and  acute  cases  this  is  an  urgent 
symptom,  which  demands  special  treatment,  for  undoubtedly 
some  cases  end  fatally  for  want  of  sleep.  A  chart  should 
always  be  kept  showing  the  exact  amount  of  sleep  an  acute 
case  is  having.  Often  such  cases  recover  without  having  more 
than  three  or  four  hours  natural  rest  each  night,  but  no 
patient  should  be  allowed  to  continue  without  any  sleep  for 
more  than  two  nights.  The  previous  habits  as  regards 
sleep  should  be  taken  into  account,  some  people  requiring 
more  than  others,  whilst  others  again  sleep  more  than  they 
allow.  Any  underlying  somatic  cause  for  insomnia  should 
be  corrected,  such  as  digestive  errors,  constipation,  chest, 
kidney,  or  genito-urinary  troubles,  neuralgias,  etc.  The  pulse 
is  a  fairly  good  indicator  as  to  the  state  of  the  cerebral 
circulation,  viz.  its   rapidity,  volume,  and    tension,  whilst   a 


GENERAL   TREATMENT  305 

blood  examination  will  give  an  estimate  of  any  anaemia  and 
of  any  possible  toxaemia,  and  the  patient  should  be  treated 
accordingly.  In  most  cases,  however,  insomnia  is  due  to 
an  excess  of  fatigue  products ;  diluent  drinks  should  therefore 
be  encouraged,  and  an  occasional  Mercurial  purge  followed  by 
a  saline  draught  should  be  given.  Old  people  with  a  tendency 
to  acidity  are  frequently  benefited  by  alkalies.  All  stimulants 
such  as  coffee,  tea,  tobacco,  as  well  as  alcohol,  and  hypnotics 
should  be  given  only  by  medical  orders.  The  patient  should 
retire  to  bed  at  a  fixed  hour,  and  sleep  should  be  induced  by 
auto-suggestion,  having  mental  calm  restored  to  him  so  far  as  is 
possible,  by  the  removal  of  all  emotional  and  ideational  stimuli. 
Hypnotism  is  rarely  of  use  in  insanity  to  promote  sleep. 

Townspeople  who  are  accustomed  to  noises  sometimes 
become  sleepless  in  the  country  and  vice  versa,  but  generally 
speaking,  the  bedroom  should  be  absolutely  quiet,  well- 
ventilated,  at  a  medium  temperature,  and  darkened.  The 
clothing  should  be  sufficient,  the  feet  should,  if  necessary,  be 
warmed  by  a  hot  bottle  and  the  head  be  propped  up  comfortably 
on  a  pillow.  A  bath  before  retiring  to  bed  often  promotes 
sleep,  as  does  also  some  refreshment  in  the  form  of  warm  milk 
and  biscuits,  or  some  hot  toddy,  or  a  pint  of  stout,  or  using  a 
pillow  or  bag  of  hops. 

For  the  routine  treatment  of  the  condition,  reliance  should 
be  placed  on  the  general  dietetic  and  open-air  treatment  of  the 
patient,  with  the  regulation  of  the  functions  of  the  body,  the 
discontinuance  of  all  work,  and  the  removal  of  all  possible 
causes  of  disorder. 

Rarely  is  insomnia  to  be  reckoned  as  a  cause  of  insanity, 
although  it  is  one  of  its  most  frequent  symptoms,  and  if  pro- 
tracted it  needs  treatment  by  hypnotics  when  other  means  fail. 
Chemical  restraint,  however,  if  injudiciously  applied,  is  as  bad  as 
or  even  worse  than  mechanical  restraint,  for  the  delicate  struc- 
ture of  the  cortex,  and  the  blood,  can  be  irretrievably  damaged 
by  powerful  drugs.  It  is  usually  best  to  give  a  full  dose  at 
night,  to  be  repeated  after  a  short  interval  if  necessary,  in  order 
to  produce  sleep,  rather  than  to  give  potent  sedatives  in  smaller 
doses  continuously  day  after  day.  In  private  single  care 
such  drugs  are  no  doubt  required  more  than  in  institutions, 
and  therefore  the  latter  course  of  treatment  has  more  advocacy 


306  MENTAL   DISEASES 

from  a  strictly  medical  point  of  view.  By  quieting  a  patient 
artificially  it  does  not  necessarily  follow  that  any  real  benefit 
to  him  is  obtained,  so  far  as  the  mental  disorder  is  concerned,  at 
all  events  when  it  is  fully  established.  The  m^ain  purpose  of 
hypnotics  should  be  to  restore  the  rhythmic  habit  of  sleep, 
and  thus  to  save  the  patient  from  exhaustion.  In  the  early 
stage  it  is  true  that  sometimes  attacks  are  averted  by  such 
drugs,  but  they  should  be  carefully  chosen  with  due  regard 
to  the  age  and  idiosyncrasy  of  the  patient,  and  they  should 
be  changed  from  time  to  time. 

It  should  be  remembered  how  easy  it  is  to  establish  a 
drug  habit  in  some  patients,  and  accordingly  the  practitioner 
should,  if  possible,  avoid  giving  such  prescriptions,  or  ordering 
tabloids  that  can  be  easily  procured  by  patients  afterwards 
without  medical  advice.  In  institutions,  except  at  the  outset 
of  insanity,  these  drugs  should  be  used  as  little  as  possible.  Of 
those  in  general  use  the  following  may  be  mentioned. 

Hypnotics  and  Sedatives. — Paraldehyde,  3j  to  3iv  given 
at  bed-time  in  some  emulsifying  agent  such  as  quillaia  water, 
with  a  little  syrup  of  orange,  or  stimulant,  to  allay  its  nauseous 
taste,  is  one  of  the  safest  hypnotics  to  be  administered.  It  is 
a  stimulant  to  the  heart,  it  acts  quickly,  and  produces  deep 
sleep  at  first,  which  is  followed  by  a  natural  state  of  uncon- 
sciousness for  some  hours.  Its  disagreeable  exhalation  un- 
fortunately lasts  during  the  following  morning,  and  sometimes 
it  disturbs  the  appetite,  and  with  some  patients,  if  frequently 
given,  it  irritates  the  bronchi. 

Chloral  Hydrate,  gr.  xx  to  gr.  xl,  also  acts  quickly,  and  should 
be  given  in  bed.  Its  cardiac  and  respiratory  depression  should  be 
noted,  but  its  action  is  very  satisfactory,  especially  in  Alcoholic 
insanity.  It  should  not  be  given  to  old  people  with  fatty 
hearts,  or  to  others  with  valvular  heart  or  with  lung  disease, 
and  it  should  only  be  given  to  General  Paralytics  with  caution. 
It  sometimes  causes  a  craving,  and  a  habit  may  thus  become 
established.  It  is  the  main  factor  in  the  patent  preparation 
of  Bromidia,  3ss  to  5ij  (which  contains  also  Bromide  of  Potas- 
sium, Hyoscyamus,  Cannabis  Indica,  Aniseed,  Syrup  and 
water).  Chloralamide,  gr.  xx  to  xl,  is  more  in  favour  with 
Neurologists  than  Alienists.  It  produces  sleep  in  some  mild 
emotional  cases. 


GENERAL   TREATMENT  307 

Amylene  Hydrate,  3j  to  3ijj  is  fairly  reliable,  but  expensive. 
It  has  a  somewhat  unpleasant  taste,  which,  however,  can  be 
disguised  by  giving  it  with  peppermint  water. 

The  Broynides — of  Potassium,  Sodium,  or  Ammonium — are 
suitable  for  mild  cases ;  of  these  compounds  the  Potash  salt 
easily  ranks  first,  in  doses  of  3ssto  3ij  given  with  camphor  or 
chloroform  water,  or  the  three  salts  can  be  given  together.  Of 
all  sedatives  they  are  probably  the  least  harmful,  given  over  a 
prolonged  term  if  such  is  absolutely  necessary,  yet  even  they 
tend  towards  dementia  and  derange  digestion,  when  given  in 
full  doses.  If  any  acne  spots  supervene,  they  may  be  controlled 
by  the  admixture  of  two  or  three  minims  of  Liq.  Arsenicalis 
with  each  dose.  The  Bromides  are  also  usefully  combined  with 
other  soporifics,  such  as  Tinct.  Hyoscyami  3ss  to  1)i],  or  Tinct. 
Cannabis  Indicae  3ss  to  q],  or  Succ.  Conii  3j  5  or  with  Tinct. 
Digitalis  3^8,  which  in  such  doses  seems  to  have  a  calming 
influence  on  the  cerebral  circulation.  The  Bromides  also 
prolong  and  intensify  the  effect  of  Chloral,  Paraldehyde  and 
Amylene  Hydrate  and  are  usefully  prescribed  with  them. 

Medinal,  gr.  v  to  gr.  x.  Veronal,  gr.  v  to  gr.  x,  and  Trional, 
gr.  XV  to  gr.  XXX,  are  fairly  tasteless  powders  and  are  all  hypno- 
tics in  frequent  use.  They  are  best  given  in  warm  milk  and 
act  within  an  hour.  Medinal  is  the  most  soluble  and  it  suits 
sleepless  Confusional  cases  in  young  people  admirably.  Veronal 
is  less  certain,  but  it  prolongs  insufficient  sleep.  Trional  is 
efficacious  both  in  young  and  in  old  people. 

SulpJional,  gr.  xx  to  gr.  xl,  is  also  a  tasteless  powder.  It 
is  not  very  soluble,  and  therefore  should  be  given  in  milk.  It 
has  a  delayed  action,  and  it  should  be  given  four  hours  before 
retiring  to  bed.  It  has  a  cumulative  action  and  keeps  a  patient 
quiet  the  next  day,  and  if  repeated  on  a  second  night,  its  effect 
is  more  pronounced.  It  is  a  motor  depressant,  and  is  there- 
fore very  useful  in  Mania.  It  suits  old  people  well.  Patients 
who  are  given  this  drug  should,  however,  be  induced  to  drink 
as  much  fluid  as  possible  and  the  bowels  should  be  kept  open. 
For  the  toxic  symptoms,  which  consist  of  muscular  inco- 
ordination, speech  defect,  derangement  of  the  appetite,  and 
vomiting,  equal  parts  of  milk  and  lime-water  should  be  given. 
In  more  pronounced  cases  Sulphonal  has  a  destructive  action 
on  the  blood  corpuscles,  resulting  in  hsematoporphyrinuria,  a 


308  MENTAL   DISEASES 

condition  which  may  also  be  caused  by  Trional,  and  which 
generally  terminates  fatally.  It  should  therefore  be  given  with 
caution,  especially  to  patients  who  are  constipated.  It  is 
sometimes  usefully  combined  with  Trional,  and  thereby  a  more 
immediate  effect  is  produced. 

Opium,  gr.  ^  to-gr.  ij,  and  Morphia,  gr.  ^  to  gr.  +,  are  not 
so  often  given  to  the  insane  excepting  agitated  Melancholiacs, 
Alcoholic  and  other  Confusional  cases  and  some  Paranoiacs. 
With  other  sedatives  they  are  usefully  combined  in  the  form  of 
Liq.  Opii  Sedativ,  1T\  v  to  Tr[  xx,  or  Liq.  Morph.  Bimeconat 
TT]^  X  to  Tr[  XXX  with  Belladonna,  Bromides,  etc.  Care  must  be 
exercised  in  prescribing  Opiates  for  the  aged,  or  for  those  with 
kidney,  lung,  or  liver  disease.  They  dry  up  the  secretions, 
and  their  constipating  effect  must  be  guarded  against  as  well 
as  their  effect  on  the  appetite.  They  are  essentially  given  for 
the  insomnia  dependent  on  pain,  exhaustion,  and  anxiety.  The 
dangers  of  a  drug  habit  must  not  be  overlooked,  especially  if 
Morphia  be  administered  hypodermically,  which  is  rarely 
necessary  or  advisable. 

Hyoscine  Hydrobromate  or  Scopolamine.,  gr.  ^^  to  gr.  -V 
hypodermically,  or  up  to  gr.  ^5-  by  the  mouth  or  rectum  is 
a  powerful  motor  depressant  which  should  only  be  used  for 
emergency  purposes,  and  is  then  sometimes  given  with  Morphia. 
It  paralyses  the  motor-nerve  endings,  frequently  confuses  a 
patient,  and  does  not  cause  healthy  sleep.  It  sometimes  in- 
duces visual  hallucinations  which  terrorise  a  patient,  the 
throat  becoming  parched,  and  the  face  pallid.  It  has  a  bad 
effect  on  the  general  nutrition,  and  is  not  to  be  recommended 
except  for  violent  cases.  Hyoscyamine,  gr.  yV  and  Duhoisine, 
gr.  yi-jj  have  similar  actions  although  less  pronounced.  Visual 
hallucinations  are  even  more  frequent  with  Hyoscyamine. 

Urethane,  gr.  xx  to  gr.  xl,  is  fairly  tasteless  and  is  very 
soluble.     It  produces  hght  sleep  and  it  can  be  given  to  children. 

Adalin,  gr.  x  to  gr.  xx,  is  safe  but  is  nearly  insoluble.  It 
is  both  hypnotic  and  sedative. 

Asjnrin,  gr.  x,  Antipyrin,  gr.  x,  and  Phenacetin,  gr.  v  to 
gr.  X,  are  sometimes  given  for  the  insomnia  associated  with 
nervous  headache,  etc. 

Other  Medicinal  Treatment. — In  treating  the  sleepless- 
ness and  restlessness  of  mental  disease,  it  is  more  important  to 


GENERAL   TREATMENT  309 

have  regard  to  the  general  bodily  condition  and  health,  and 
to  correct,  if  possible,  what  is  amiss,  than  to  give  sedatives 
and  hypnotics  that  allow  the  causes  to  continue  untreated. 
To  this  end  all  hygienic  measures  should  be  adopted,  and 
seeing  that  much  insanity  is  toxic  in  nature,  patients  should 
be  encouraged  to  drink  a  sufficiency  of  water  to  flush  out 
their  systems. 

Although  it  may  be  useless  to  think  of  treating  a  delusion 
or  an  emotional  state  by  means  of  drugs,  yet  it  must  be  borne 
in  mind  that  the  underlying  brain  disorder  is  often  dependent 
on  blood  and  other  bodily  conditions,  which  are  amenable 
to  medicinal  treatment.  Too  often  is  it  said  of  the  asylum 
physician  that  he  does  nothing  but  house  his  patients  in 
safe  surroundings.  The  medical  spirit  should  always  be 
encouraged,  even  if  a  bottle  of  medicine  is  only  the  outward 
and  visible  sign  of  a  process  of  suggestion  which  benefits 
the  patient.  Although  over-drugging  may  be  pernicious,  it 
is  certain  that  therapeutic  scepticism  or  pessimism  is  to  be 
deprecated.  The  primse  viae,  so  frequently  deranged,  must  be 
re-established.  Constipation,  so  often  a  feature  in  insanity,  has 
already  been  referred  to.  The  appetite  is  generally  improved 
by  means  of  Nitro-Hydrochloric  Acid  and  bitters,  or  by  other 
stomachics.  Attention  should  always  be  given  to  the  state  of 
the  mouth,  as  carious  teeth  are  frequently  a  source  of  toxsemic 
infection.  The  daily  use  of  mouth  washes  should  always  be 
encouraged. 

When  there  is  much  flatulence,  or  when  the  excreta  are 
offensive,  intestinal  antiseptics  are  sometimes  helpful,  such  as 
Salol,  ^-Naphthol,  Bismuth  Salicylate,  the  Lactic  Acid  bacillus 
or  Sour  milk.  Paraffin,  or  in  mild  cases.  Peppermint.  The 
stomach  is  improved  in  toxic  cases  by  a  daily  wash-out  with 
Potassium  Permanganate  by  means  of  the  oesophageal  tube. 
In  others,  also,  the  large  intestine  may  be  similarly  flushed 
out  per  rectum  from  time  to  time.  This  is  particularly  neces- 
sary if  there  is  any  tendency  to  Dysentery,  the  infective 
variety  being  unfortunately  common  in  some  asylums.  The 
bowel  irrigation  in  such  cases  can  be  carried  out  by  various 
disinfectants,  i.  e.  Quinine,  Izal,  etc. 

Bladder  conditions  have  already  been  mentioned.  Menstrual 
disorders  are  generally  secondary  to  blood  conditions,  but  the 


310  MENTAL   DISEASES 

flow  can  often  usefully  be  promoted  by  hot  sitz -baths  and  by 
emmenagogues.  Any  vaginal  discharge  should  receive  treat- 
ment by  antiseptic  douches,  and  it  must  be  remembered 
that  sometimes  foreign  bodies  are  introduced  into  the  vagina 
by  an  insane  patient  (and  occasionally  even  into  the  bladder), 
and  require  removal. 

Conditions  such  as  Gout,  Syphilis,  Anaemia,  Diabetes,  or 
Phthisis  need  treatment  on  special  lines,  whilst  isolation  is 
imperative  for  the  last  mentioned,  and  for  Ulcerative  Colitis 
(Asylum  Dysentery). 

Much  may  be  done  by  judicious  prescription  of  tonics 
when  the  acute  symptoms  of  insanity  have  subsided.  Amongst 
these  may  be  mentioned  Cod-liver  Oil  and  Maltine,  Syrup 
Hypophosph.  Co.,  Quinine,  Iron,  and  Arsenic.  Strychnine,  and 
Nux  Vomica  (or  Easton's  Syrup),  should  be  given  in  small  doses 
at  first,  and  very  cautiously  to  old  people. 

Latterly  the  Lymphoid  Compounds  (Glycero-Phosphates) 
and  Organic  Extracts  have  been  given,  from  which  much  may 
be  expected  in  Neurasthenia  and  Exhaustion  states,  but  they 
are  disappointing  in  Dementia  Prsecox  and  Organic  Psychoses. 

Vaccines  have  so  far  not  been  of  much  avail  in  conditions 
associated  with  insanity.  The  injection  of  anti-streptococcic 
serum  in  Puerperal  cases,  and  of  bacillus  coli  in  some  auto-toxic 
cases  have  sometimes  been  beneficial.  Lewis  Bruce  reports 
good  results  from  the  production  of  leucocytosis  by  means  of 
the  subcutaneous  injection  of  2  com.  of  Terebene,  or  of  Cinnamic 
acid.  Many  insane  persons  mentally  improve  during  inter- 
current inflammatory  disorders,  and  sometimes  recover,  so 
that  treatment  on  these  lines  should  not  be  altogether  tabooed. 
In  General  Paralysis  some  patients  improve  by  the  injection 
of  Nucleinate  of  Sodium  or  Nucleic  Acid,  by  which  again, 
leucocytosis  is  produced. 

Thyroid,  given  in  tabloids  or  as  the  powdered  extract,  is 
not  only  given  for  Myx oedema  and  Cretinism,  but  is  a  recog- 
nised form  of  treatment  in  Stuporous  states,  especially  those 
associated  with  Melancholia.  For  this  purpose  it  should  be 
given  in  increasing  doses  for  four  days,  viz.  from  gr.  x  to  gr.  xx 
ter  die,  and  then  be  gradually  diminished,  and  discontinued 
on  the  eighth  day ;  the  patient  should  be  kept  in  bed,  and 
the  pulse  and  temperature  watched.     The  patient  looks  ill 


GENERAL   TREATMENT  311 

under  the  treatment  and  loses  weight,  but  it  produces  mental 
disturbance  which  sometimes  leads  to  recovery. 

Of  other  drugs  that  are  sometimes  indicated  may  be  men- 
tioned those  that  reduce  blood-pressure.  Amyl  nitrite  acts 
quickly,  but  is  somewhat  too  evanescent,  while  Nitrite  of 
Sodium,  gr,  ij  to  gr.  v,  and  Liq.  Trinitrini,  Tl|  ij  to  Vi{  v,  though 
slower  in  action,  have  a  more  pronounced  effect.  The  cases 
most  frequently  benefited  by  them  are  those  of  Melancholia 
associated  with  high  arterial  tension.  However,  the  best 
drug  for  this  purpose  is,  perhaps,  Erythrol  tetra-Nitrate,  gr.  J 
to  gr.  ij,  in  tabloids.  The  blood-pressure  can,  on  the  other 
hand,  be  raised  in  some  cases  of  low  nervous  vitality  by 
Alcohol — especially  in  the  form  of  Champagne ;  by  Digitalis, 
Ergotin,  Pituitrin,  Supra-Renal  Extract,  and  by  saline  injec- 
tions, the  last  mentioned  being  used  in  states  of  Collapse. 

Urotropin,  gr.  v  to  gr.  x,  t.d.s.,  besides  having  almost  a 
specific  antiseptic  action  on  the  urine  and  bladder,  acts 
probably  in  a  similar  manner  on  the  cerebro-spinal  fluid, 
for  many  General  Paralytics  are  benefited  by  its  adminis- 
tration. 

Some  mental  diseases  are  associated  with  a  feeble  state  of 
nutrition  and  with  deficient  chest  movements.  Lung  troubles 
are  therefore  apt  to  occur,  such  as  Bronchitis,  Pneumonia, 
Pleurisy  and  Phthisis ;  frequently  the  symptoms  are  slight  and 
the  patient  gives  little  indication  of  the  nature  of  his  illness. 
Stimulating  expectorants  are  generally  indicated.  Other 
diseases  are,  however,  often  masked,  such  as  Aneurysm, 
Cancer,  Hernia — which  demand  special  treatment.  For  the 
drug  treatment  of  Epilepsy,  General  Paralysis,  and  of  other 
conditions  associated  with  insanity,  the  special  Chapters  must 
be  consulted. 

Surgical  Operations,  etc. — The  insane  usually  take  an- 
aesthetics as  well  as  do  ordinary  people,  and  for  the  most  part, 
necessary  operations  can  be  performed  without  undue  risks. 
In  most  cases,  the  consent  of  the  patient  should,  however, 
first  be  obtained  if  he  is  not  devoid  of  all  volition  and  intelli- 
gence ;  the  relatives  should  also  be  informed,  and  their  sanction 
should  be  procured  in  serious  cases.  Sometimes  mechanical 
restraint  is  required  to  prevent  the  dressmgs  being  interfered 
with. 


312  MENTAL   DISEASES 

Venesection  and  Transfusion  are  occasionally  practised. 
Blisters  behind  the  ears,  and  Counter-irritants  are  sometimes 
appHed.  Hsematoma  auris  should  be  at  once  treated  by 
painting  it  with  Liq.  Epispasticus,  by  which  effusion  is  ab- 
sorbed and  cicatrisation  minimised.  The  occurrence  of  Frac- 
tures, Accidental  and  Suicidal  wounds.  Strangulated  Hernia, 
etc.,  renders  a  knowledge  of  Surgery  a  necessary  qualification 
in  every  medical  officer  of  an  institution  for  the  insane. 
Gynecological  operations  seldom  do  any  good  in  insanity.  Cases 
for  trephining  such  as  decompression  are  also  rare  in  asylums. 
Seldom  is  there  any  real  localising  cerebral  lesion  in  the  insane. 
Again,  removal  of  cerebro-spinal  fluid  to  diminish  tension  is 
of  little  use,  except  in  some  cases  of  Meningitis.  It  is,  however, 
important  sometimes  to  examine  the  fluid  for  diagnostic 
purposes  to  see  whether  it  is  turbid  or  clear,  and  whether, 
microscopically,  lymphocytosis  is  present,  and  whether  there 
are  any  organisms  in  the  sediment. 

Lumbar  Puncture. — This  operation,  which  we  owe  to 
Quincke,  is  best  performed  by  requesting  the  patient  to  bend 
forward  over  a  chair  in  a  stooping  position,  in  order  to  separate 
the  spinous  processes  as  much  as  possible.  Draw  a  line  across 
the  back  at  the  level  of  the  iliac  crests  which  will  pass  over 
the  4th  lumbar  spine.  This  is  well  below  the  end  of  the  spinal 
cord,  as  the  latter  terminates  at  the  2nd  lumbar  vertebra. 
A  spot,  \  in.  below  the  4th  spine  and  to  the  side  of  the  middle 
line,  should  be  chosen,  the  skin  having  been  cleaned  and  anti- 
septicised.  A  10  or  20  c.cm.  glass  syringe  is  required,  with  a 
hollow  platinum  needle  and  a  stilette,  4  ins.  in  length,  and  the 
entire  apparatus  must  be  thoroughly  sterilised  by  boiling. 
The  stilette,  being  removed,  the  needle  having  been  adjusted  to 
the  syringe,  is  thrust  through  the  skin  forwards  and  inwards 
between  the  laminse  towards  the  spinal  canal,  for  a  distance 
of  SJ  ins.  in  an  ordinary  person.  Should  it  reach  the  body 
of  the  vertebra,  it  should  be  withdrawn  a  little.  When  the 
needle  is  removed  from  the  syringe,  if  the  fluid  does  not  flow 
after  a  few  seconds,  the  stilette  should  be  re-introduced,  as 
the  lumen  is  sometimes  blocked  by  blood ;  frequently  gentle 
suction  with  the  syringe  is  also  necessary.  The  first  few  drops 
of  fluid,  if  discoloured,  should  be  allowed  to  escape.  Then 
about  5  c.cm.  to  10  c.cm.  should  be  collected  in  a  sterilised 


GENERAL   TREATMENT  313 

test  tube,  which  should  be  phigged  with  sterilised  cotton 
wool.  On  withdrawing  the  needle,  the  skin  should  have 
collodion  applied,  and  the  patient  should  lie  in  the  recumbent 
position  for  an  hour. 

Mental  and  Moral  Hygiene. — This  is  the  very  essence  of 
all  successful  asylum  treatment,  whilst  it  is  also  recognised  as 
an  important  adjunct  to  medical  treatment  in  most  depart- 
m.ents  of  practice.  Patients  cannot  be  regarded  as  mere 
receptacles  for  medicines  or  vaccines  only,  and  "  psychic  " 
treatment  must  not  be  overlooked.  The  so-called  influence  of 
the  mind  on  the  body  is  in  reality  dependent  upon  the  control 
of  the  cortical  neurons  over  the  lower  neurons  of  the  nervous 
system.  Without  entering  into  the  possibility  of  telepathy, 
the  influence  of  one  mind  on  another  mind  in  restoring  abnormal 
association  nerve  currents  to  the  normal  is  effected  through 
the  channels  of  the  special  senses  and  the  higher  motor  mechan- 
ism. Much  can  be  done  in  this  matter  through  the  personality 
of  the  physician,  some  medical  men  being  happily  gifted  in 
this  respect.  A  good  deal  depends  on  the  tactful  management  of 
patients  in  general,  and  this  applies  particularly  to  the  influence 
of  nurses.  The  tout  ensemble  of  an  institution  should  have 
the  loyal  and  enthusiastic  support  of  the  entire  staff  to  promote 
the  recovery  of  its  patients.  Psycho-therapeutics,  or  what 
embraces  the  mental  and  moral  treatment  of  insanity,  should 
be  utilised,  along  with  medicinal  and  other  agents  in  the  treat- 
ment of  all  cases. 

In  the  exercise  of  moral  guidance  and  control,  be  the 
patient  ever  so  bad,  it  must  be  borne  in  mind  that  he  is  insane, 
and  that  severe  measures  are  entirely  out  of  court.  The  most 
that  should  be  done  is  to  withdraw  privileges  in  some  instances, 
in  order  to  promote  discipline  and  obedience  to  orders.  It  has 
already  been  mentioned  that  any  one  who  ill-treats  a  patient, 
or  wilfully  neglects  him,  on  conviction,  is  liable  to  fine  or 
imprisonment. 

Besides  the  effect  of  personality  exerted  mainly  through 
conversation  with  the  patient,  the  mental  influences  of  occupa- 
tion and  environment  have  to  be  considered,  both  as  regards 
the  conscious  and  subconscious  life  of  the  patient.  To  both 
of  these  influences  further  reference  will  be  made  later.  Normal 
occupation  means  the  exercise  of  attention  to  a  varying  extent, 


314  MENTAL   DISEASES 

and  this  is  wanting  in  many  of  the  insane,  who  are  already 
preocc^^pied  in  a  morbid  sphere  of  thought  and  activity.  The 
isolation  of  the  patient  from  relatives,  and  his  removal  to  fresh 
scenes,  experience  teaches  us  as  being  most  beneficial  in  estab- 
lishing a  fresh  nexus  of  ideas.  In  taking  a  patient  away  from 
his  home,  no  deception  should  be  practised  on  him,  and  the 
physician  and  nurses  should  deal  as  frankly  and  truthfully 
with  an  insane  patient  throughout  his  iUness,  as  with  an  ordi- 
nary individual.  Nothing  should  be  promised  that  cannot 
be  faithfully  carried  out.  What  is  now  generally  termed 
"  suggestion  "  forms  an  important  element  in  the  cure  of 
the  patient.  This  is  habitually  used  in  the  sense  of  conscious 
persuasion,  as  well  as  in  that  of  unconscious  mental  influence, 
to  which  it  should  properly  be  applied.  Improvement  in 
symptoms  and  conduct  should  thus  be  suggested,  and  what- 
ever amelioration  occurs,  should  be  indicated  to  the  patient, 
and  should  be  utihsed  to  the  best  advantage  in  a  helpful 
direction.  Neither  the  medical  attendant  nor  the  nurses 
should  be  ruffled  by  words  of  abuse ;  they  should  regard  such 
incidents  as  bemg  merely  due  to  mental  disease,  and  should 
take  no  serious  notice.  Good  manners  and  politeness  towards 
the  patient  should  be  required  of  all  people  having  care  of 
an  insane  person.  A  cheerful  countenance  and  a  happy  mood 
should  be  expected  from  every  member  of  the  staff.  The 
physician  should  exercise  patience,  and  Hsten  to  afl  statements, 
however  wearisome,  that  an  insane  person  iterates.  He  must 
show  that  he  takes  a  real  interest  in  his  welfare ;  moreover,  a 
fund  of  sympathy  and  fellow-feeling  creates  confidence  in  a 
patient,  and  is  of  good  influence  in  treatment.  Words  of 
encouragement  are  comforting,  and  it  should  be  remembered 
that  many  of  the  insane  are  abnormally  sensitive  and  easily 
take  offence,  whilst  others,  differently  constituted,  can  be 
treated  with  good-humoured  satire. 

The  attitude  towards  delusions  and  hallucinations  should 
vary  in  accordance  with  the  temperament  of  a  patient. 
Never,  however,  should  he  be  allowed  to  think  that  his 
deluded  beliefs  are  accepted  by  his  medical  attendant.  It 
is  usually  best  to  ignore  them  as  much  as  possible.  Too  much 
appeal  to  the  disordered  reasoning  processes  only  serves  to 
reinforce   the   disorder   and    to    irritate    a    patient.      When, 


GENERAL   TREATMENT  315 

however,  erroneous  associations  are  not  fully  established, 
or  are  about  to  resume  their  normal  course,  a  patient  often 
is  in  a  vacillating  state,  as  regards  his  morbid  ideas,  and 
conversations  with  explanations  sometimes  do  good,  and 
in  time  he  sees  the  mistakes  he  has  made.  Even  some 
Paranoiacs  are  helped  by  the  engrafting  of  normal  ideas  on 
old  delusional  trends  of  thought,  by  persuasion  as  well  as 
suggestion,  and  their  egoistic  feelings  may  sometimes  be 
modified  by  the  constant  reminder  that  they  are  much  like 
other  people  ;  the  majority,  however,  it  must  be  acknowledged, 
are  not  affected  by  such  means.  What  has  taken  years  to 
evolve,  as  a  rule,  is  not  likely  to  be  undone  in  a  short  time 
by  this  mode  of  treatment  alone.  With  regard  to  Obsessional 
cases,  and  particularly  those  with  morbid  fears,  "insight" 
is  still  present,  and  therefore  a  psychological  examination  into 
the  production  of  such  disorders  with  educated  patients  is 
not  without  benefit.  For  this  purpose  doctors  and  cultured 
companions  are  provided  for  the  upper  classes,  but  even  the  asso- 
ciation of  insane  patients  of  the  same  class  is  often  helpful, 
the  one  patient  seeing  the  faults  of  others,  and  correcting  his 
own  disorder  unconsciously  or  consciously. 

Psycho-analysis,  as  it  is  called,  has  largely  come  into  vogue 
in  recent  times.  This  comprises  a  critical  investigation  into 
the  previous  life  of  the  patient,  with  a  view  to  digging  up 
suppressed  morbid  association  complexes,  which  may  be 
concerned  with  his  present  disordered  state.  It  is,  of 
course,  only  applicable  to  patients  who  are  able  to  converse, 
and  to  enter  intelligently  into  their  cases.  It  has  been 
largely  studied  by  Freud  of  Vienna,  and  the  subconscious 
mind  of  the  patient  is  unveiled  so  far  as  is  possible.  Thus, 
the  investigation  of  dreams  sometimes  throws  light  on  the 
essence  of  a  psychic  trauma,  which  is  at  the  root  of  the  patient's 
morbid  ideas  and  moods.  Or  laying  open  the  past,  by  what 
is  called  "  free  association  "  may  unconsciously  reveal  an 
exaggerated  emotional  bias  concerned  with  some  incident, 
trifling  or  important,  that  occurred  years  ago.  The  patient 
is  asked  to  state  every  thought  and  word  that  casually  occur 
to  him.  When  nothing  can  be  discovered  by  these  methods, 
"  word  associations "  have  been  utilised,  according  to  the 
system  of  Jung,  by  which  unconsciously  the  patient  may  give 


316  MENTAL   DISEASES 

a  clue  to  morbid  submerged  complexes,  which  may  possibly 
by  argument  and  conversation  be  broken  up.  Thus  the  reaction 
word  of  the  patient  to  each  word  uttered  by  the  operator  can, 
by  its  nature,  or  by  the  delay  in  response,  put  the  investigator 
on  the  right  course.  Habitually  about  one  to  two  seconds 
is  an  ordinary  reaction,  as  timed  by  a  stop-watch,  but  a  word 
bringing  to  light  a  buried  or  repressed  complex  in  conflict 
with  the  patient's  usual  nature,  and  therefore  which  has  upset 
him,  is  marked  by  a  prolongation  of  the  reaction  time,  or  by 
an  absence  of  reaction  owing  to  emotional  stress.  The  process 
is  a  laborious  and  tedious  one,  and  it  has  but  small  application 
to  the  majority  of  the  insane,  but  such  investigation  bears 
fruit  in  some  cases  of  Psychasthenia  and  Hysteria,  and  occa- 
sionally also  in  Dementia  Prsecox  and  Melancholia. 

Psycho-analysis  tends  to  unravel  the  growth  of  the  sexual 
life,  however,  to  an  undesirable  extent  in  some  instances,  if 
carried  out  minutely,  and  thus  it  may  be  harmful ;  consequently 
it  has  not  received  universal  support.  To  investigate  a 
case  properly  often  takes  an  hour  a  day  over  a  period  of 
months.  When  a  submerged  morbid  complex  is  discovered, 
it  is  not  always  possible  to  disperse  it,  and  to  re-educate 
the  patient  to  normal  habits  of  thought,  frequent  interviews, 
moreover,  are  necessary. 

Hypnotism. — ^The  hypnotic  and  the  hypnoidal  states  are 
of  little  avail  in  insanity.  In  the  first  place,  the  attention  of 
the  patient  is  difficult  to  obtain,  so  as  to  produce  these  artificial 
states,  and  thus  to  influence  him  by  suggestion,  or  to  render  him 
amenable  to  further  psycho-analysis  in  the  somnambulistic 
stage.  Some  insane  persons  can,  however,  be  hypnotised, 
but  they  are  generally  of  the  border-line  or  Psychasthenic 
class,  or  they  are  Alcoholics  or  Drug-takers,  or  they  are 
Hysterical  cases.  Frequent  repetitions  are  necessary  to  do 
any  permanent  good,  and  the  patient  needs  supervision  for 
some  time  subsequently.  Occasionally  it  is  used  in  cases  of 
obstinate  insomnia  with  success. 

Occupation  and  Exercise. — Although  insanity  neces- 
sarily impairs  the  volition  of  patients  and  deprives  them  of  the 
power  of  sustained  attention,  yet  it  is  the  physician's  duty,  in 
all  cases  who  have  passed  through  the  acute  stages,  to  provide 
such  employment,  by  work  or  anjusement,  as  the  patient's 


GENERAL   TREATMENT  317 

status  requires.  For  this  purpose,  regularity  and  routine 
are  of  the  utmost  value,  and  the  influence  of  the  good  example 
of  seeing  others  occupied  is  most  useful.  To  promote  mental 
health,  exercise  of  some  sort  is  necessary,  and  should  be  pre- 
scribed according  to  the  nature  and  inclination  of  the  patient. 
A~  due  admixture  of  both  mental  and  physical  exercise  is  best 
for  most  individuals. 

Amongst  the  poorer  classes  the  provision  for  actual  work 
is  not  so  difficult  for  either  men  or  women.  The  public  insti- 
tutions would  indeed  be  a  heavier  expense  than  they  are,  if 
patients  did  not  materially  assist  in  the  workshops,  the  farm 
and  gardens,  the  kitchens  and  laundries,  and  in  the  wards. 
Moreover,  entertainments  and  amusements,  as  a  means  of 
treatment,  are  instituted  for  them,  and  at  the  same  time 
provide  recreations  for  the  stafi. 

For  the  better  classes  in  institutions,  or  in  private  care, 
hobbies  and  occupations  may  be  devised  to  interest  the  patient, 
including  indoor  and  outdoor  sports  and  recreations — cricket, 
football,  golf,  tennis,  croquet,  gardening,  walking,  riding, 
driving,  bicycling,  motoring,  artificial  exercises,  billiards, 
cards,  draughts,  music  and  singing,  painting  and  drawing, 
literature  and  science,  typewriting  and  printing,  translating 
foreign  languages,  photography,  wood-carving,  carpentering, 
basket-making,  rug-making,  crochet  and  needlework,  etc. 

Besides  periodical  theatrical  and  musical  entertainments, 
occasional  excursions  of  various  kinds  afford  occupation  and 
food  for  the  mind.  In  some  institutions  exhibitions  of  art 
are  arranged,  to  which  patients  contribute,  and  a  magazine 
is  published.  The  influence  of  music  and  of  art  must  not  be 
forgotten,  especially  in  those  people  who  are  cultured.  The 
formerly  bare  walls  of  our  public  asylums  are  now  covered  with 
pictures,  and  books  and  papers  are  provided,  so  that  ennui 
should  scarcely  be  possible.  With  regard  to  Church  services, 
both  from  the  religious  and  the  disciplinary  points  of  view, 
these  are  very  valuable  as  a  patient  convalesces.  Only  in 
acute  cases  and  in  certain  chronic  Melancholiacs,  Paranoiacs, 
and  Epileptics  are  they  harmful,  and  the  visit  of  the  Chaplain 
undesirable. 

Social  and  Environmental  Influences. — Some  of  these 
have  already  been  included  whilst  considering  the  matter  of 


318  MENTAL   DISEASES 

occupation.  An  insane  patient  should  be  encouraged  to  be  as 
sociable  as  possible.  It  has  become  general  for  ladies  as  well 
as  gentlemen  to  act  as  companions,  and  to  associate  with 
insane  gentlemen  when  they  are  fit,  and  for  female  nurses 
to  be  engaged  in  nursing  the  male  insane,  except  in  some 
cases  with  objectionable  tendencies.  Such  association  of 
the  sexes  was  at  one  time  viewed  with  dismay  and  was 
thought  to  be  impossible,  but  it  is  of  the  utmost  value  in  in- 
stilling healthy  notions  of  life,  and  in  promoting  recovery. 
Care  must,  of  course,  be  exercised  to  guard  against  any  abuse. 
Except  in  acute,  and  in  some  special  cases,  meals  in  single  or 
private  sitting-rooms  in  institutions  should  not,  as  a  rule, 
be  encouraged,  as  a  patient  thereby  misses  opportunities  for 
improvement  which  association  with  others  produces.  The 
whole  course  of  regime  to  be  adopted  for  each  individual 
patient  should  be  ordered  by  the  physician.  The  mental 
atmosphere  should  not  be  too  stimulating,  as  thereby  risks 
of  relapses  may  be  incurred ;  neither,  on  the  other  hand,  should 
it  be  too  stagnant,  some  patients  being  apt  to  get  into  a  groove. 
Sometimes  a  walk  in  a  town  is  more  congenial  than  a  ramble 
in  the  country.  It  may  incidentally  be  mentioned  that 
smoking,  in  men  who  are  used  to  tobacco,  is  not  to  be  dis- 
couraged ;  the  habit  usually  soothes,  and  breeds  a  happy  content. 
As  a  patient  convalesces,  he  should  be  trusted  on  his  parole 
without  a  companion,  and  there  should  be  no  undue  haste 
in  procuring  his  discharge. 

The  after-care  of  patients  should  always  be  considered, 
and  no  person  after  a  severe  attack  of  insanity  should,  as  a 
rule,  return  to  the  avocation  by  which  he  gains  his  livelihood 
for  some  months.  In  the  poorer  classes,  however,  this  is  often 
impossible,  but  some  asylums  have  a  fund  from  which  they 
are  able  to  help  recovered  patients,  in  addition  to  any  small 
sums  the  Guardians  are  able  to  grant.  There  is  also  at  Dean's 
Yard,  Westminster,  the  office  of  the  After-Care  Association, 
a  philanthropic  body  which  provides  not  only  clothing  and 
money,  but  temporary  homes,  for  starting  afresh  in  life 
patients  who  are  recommended  to  it.  A  similar  Association  is 
urgently  required  to  assist  those  on  the  verge  of  a  break- 
down, especially  for  the  incipient  insane  amongst  the  poor. 
In  the  upper  classes  an  intermediate  change,  or  travelling. 


GENERAL   TREATMENT  319 

is  the  best  course  to  adopt  after  discharge,  before  returning 
home. 

3.  The  Care  of  the  Chronic  Insane  and  Mental 
Defectives 

It  cannot  be  said  truthfully  that  a  patient  never  recovers 
after  many  years  of  insanity,  yet,  such  an  event  is  a  rare 
occurrence;  most  cases  that  get  well  do  so,  as  a  rule,  within 
two  years.  On  economical,  and  other  grounds,  it  has  been 
realised  that  many  of  the  requirements  of  the  recent  and 
acutely  insane  are  not  necessary,  and  indeed  are  not  alto- 
gether suitable,  for  chronic  cases.  For  the  latter  there  is  not 
so  much  need  for  supervision  by  nurses,  and  the  medical 
visitation,  although  it  cannot  ever  be  dispensed  with,  need 
not  be  so  frequent.  At  Gheel  the  farming-out  principle  has 
been  in  vogue  for  ages,  and  in  Scotland  it  has  been  the  custom 
for  some  years  to  board  out  many  of  the  pauper  insane,  amount- 
ing even  to  one-fifth  of  the  whole  number.  The  crofters  and 
others  -are  glad  to  obtain  thereby  a  small  pittance,  and  the 
system  induces  patients  to  take  an  interest  in  the  doings  of 
the  sane,  which  is  good  for  them.  It  also  serves  to  stay  the 
necessity  for  so  much  building  of  institutions.  Inspection, 
of  course,  has  to  be  carried  out,  and  any  tendency  to  abuse 
needs  removal  by  stringent  measures.  In  England,  although 
legally  permissible,  complications  exist  so  that  such  treatment 
has  not  met  with  favour,  and  persons  willing  to  undertake  the 
charge]  of  insane  patients  at  nominal  rates  are  scarcely  to  be 
found.  Superintendents,  perhaps,  are  not  too  anxious  to  part 
with  those  patients  who  are  able  to  work  and  thus  to  relieve 
the  institutions  (and  ratepayers),  which  may  be  another  reason. 
Although  acute  and  recent  cases  are  to  some  extent  removed 
from  chronic  cases  in  most  of  the  newer  asylums,  the  same 
facilities  are  not  always  possible  in  the  older  barrack  ones,  to 
the  detriment  of  both  classes.  It  is  hoped  that  more  asylums 
on  the  Villa  or  Colony  system  will  be  instituted,  where  patients 
can  earn  a  quasi-livelihood,  and  yet  be  under  some  form  of 
control.  The  treatment  of  a  good  many  mild  dements  chiefly 
consists  in  disciplining  them  to  regular  habits  of  life,  and  when 
they  conform  thereto,  they  can  frequently  be  managed  outside  an 
institution,  and  are  capable  of  manual  work.     Some,  of  course, 


320  MENTAL   DISEASES 

are  so  defective  in  their  habits  that  continual  supervision  is 
always  requisite,  whilst  others  who  are  noisy  and  impulsive 
cannot  be  treated  away  from  an  asylum.  The  more  asylum 
life  is  bereft  of  any  prison  element,  and  the  more  it  is  approxi- 
mated to  home  life,  the  happier  are  the  patients  and  the  better 
it  is  for  them.  For  the  criminal  insane,  State  institutions 
are  necessary,  and  their  surplus  should  not  be  sent  to  county 
asylums,  as  is  the  case  at  present. 

For  idiots,  imbeciles,  and  the  congenitally  feeble-minded, 
permanent  educational  homes  and  institutions  under  medical 
management  are  required,  together  with  special  physical 
drills  and  workshops.  They  should  not  be  housed  in  the  county 
asylums.  Many  of  these  patients  are  improvable  and  are 
able  to  learn  handicrafts  under  supervision,  but  few  are  ever 
able  to  take  their  place  in  the  outside  world,  as  their  training 
has  to  be  continuous.  Their  diet  and  manner  of  eating  require 
regulation,  and  their  wet  and  dirty  habits,  as  in  the  case  of 
many  dements,  also  need  correction.  With  them,  in  par- 
ticular, the  withdrawal  of  privileges  acts  as  an  incentive 
to  good  habits,  but,  no  punitive  measures  should  ever  be 
countenanced.  It  is  hoped  that  besides  idiots  and  imbeciles 
many  of  the  feeble-minded  and  moral  defectives  will  be 
placed  in  approved  homes,  certified  houses  and  institutions, 
under  the  Mental  Deficiency  Act,  and  not,  as  hitherto,  be 
allowed  to  drift  without  any  supervision. 

In  the  upper  classes,  when  a  patient  has  passed  through 
his  acute  attack,  and  does  not  recover  in  spite  of  all  that  is 
done,  a  change  to  another  institution  is  sometimes  recom- 
mended. Better  it  is,  as  a  rule,  for  a  patient  to  have  changes 
with  special  supervision  under  leave  of  absence,  as  thereby 
he  does  not  feel  he  is  considered  a  hopeless  case.  If  a  patient 
is  suitable  for  single  care,  and  he  can  afford  it,  or  if  he  prefers 
it,  this  should  be  arranged ;  but  it  must  be  borne  in  mind 
that  sometimes  a  patient  becomes  further  deranged  under 
such  circumstances,  owing  to  lack  of  discipline  and  routine, 
and  he  has  to  return  to  an  institution.  Some  cases  improve 
so  as  to  be  able  to  live  at  home,  others,  especially  females, 
can  live  in  religious  communities.  The  chronic  insane  of  the 
upper  classes  mostly,  have  an  annual  sea- side  visit  which 
promotes  their  bodily  health,  and  the  change  of  scene  is  good 


GENERAL   TREATMENT  321 

for  them,  yet  many  are  glad  enough  to  return  to  what  they 
regard  as  their  home  in  institutions.  This  is  to  be  remembered 
when  transfer  is  suggested  in  the  case  of  any  one  who  has  lived 
for  years  in  one  course  of  routine ;  especially  in  the  aged  does 
such  a  change  invariably  do  harm,  as  the  patient  often  dies 
soon  after. 

Conclusion. — The  student  will  find  that  the  subject  of 
Mental  Diseases  embraces  some  of  the  deepest  problems  that 
can  be  encountered,  and  that  its  study  is  of  the  profoundest 
interest.  The  elucidation  of  acute  mental  disorders  needs 
all  the  knowledge  he  can  attain  in  the  sciences  of  anatomy, 
physiology,  chemistry,  bacteriology  and  pathology :  the 
unravelling  of  the  laws  of  heredity  requires  much  patient 
investigation,  and  the  analysis  of  mental  cases  involves  a 
sound  knowledge  of  psychological  methods ;  whilst,  as  has 
already  been  mentioned,  the  symptoms  of  bodily  disease  in 
the  insane  being  so  often  latent,  his  clinical  aptitudes  should 
be  of  the  highest  quality  to  enable  him  to  detect  such  disease, 
and  thus  to  be  successful  in  its  treatment. 

Moreover,  the  practice  of  Psychiatry  calls  for  the  play  of 
humanity,  in  addition  to  scientific  investigation,  and  in  no 
branch  of  Medicine  are  qualities  of  heart,  as  well  as  of  head, 
more  requisite  than  in  the  management  of  the  insane.  In 
general  practice,  or  in  whatever  path  of  professional  life  the 
student  is  destined  for,  he  will  be  likely  to  find  himself  con- 
fronted with  a  mental  case.  This  may  tax  his  resources  to 
their  utmost,  unless  he  has  given  due  attention  to  the  subject 
in  his  student  days.  If,  on  the  other  hand,  he  makes  the 
study  and  practice  of  Psychiatry  his  special  work,  it  will 
bring  with  it  the  satisfaction  of  taking  part  in  the  progressive 
movement  for  the  prevention  of  mental  affliction,  for  its  cure 
when  possible,  and  for  its  care  when  recovery  is  impossible. 
This  movement  is  attracting  the  increasing  attention  of 
the  profession  and  of  the  public  alike,  and  much  is  to  be 
expected  in  the  near  future  from  the  steady  advances  in  our 
knowledge. 


APPENDIX 

The  following  are  the  Reception  Forms  for  England  and  Wales.  (The 
characteristic  differences  in  the  Reception  of  Patients  in  Scotland  and  Ireland, 
and  under  the  Mental  Deficiency  Act,  are  mentioned  on  pages  275-278.) 

A. — Private  Patients. 

(a)  Two  Medical  Certificates. 

Petition  and  Statement  of  Relative. 
Order  of  Justice. 
(6)    Urgency  Order  and  Statement  of  Relative. 

One  Medical  Certificate  with  Statement  for  Urgency. 
B. — Pauper  Patients  (or  any  insane  person  Wandering  at  Large.) 

Summary   Order  of   Justice  and  Statement  of    Relieving 

Officer. 
One  Medical  Certificate. 

The  notes  on  the  fly-leaf  of  a  Medical  Certificate  are  : — 

Two  Medical  Certificates  on  separate  sheets  of  paper  are  required  in 
support  of  a  Petition  for  an  Order  for  the  Reception  of  a  Private  Patient. 
One  of  these  Certificates  should,  whenever  practicable,  be  under  the  hand  of 
the  usual  Medical  Attendant  (if  any)  of  the  alleged  lunatic. 

Each  of  the  Medical  Practitioners  who  signs  a  Certificate  must  personally 
examine  the  alleged  lunatic  separately  from  the  other,  and  not  more  than 
seven  days  before  the  presentation  of  the  Petition. 

Neither  of  the  certifying  Medical  Practitioners  may  be  the  father  or 
father-in-law,  mother  or  mother-in-law,  son  or  son-in-law,  daughter  or 
daughter-in-law,  brother  or  brother-in-law,  sister  or  sister-in-law,  partner  or 
assistant  of  the  other  of  them. 

One  Medical  Certificate  is  sufficient  in  the  case  of  an  Urgency  Order.  In 
such  case  the  certifying  Medical  Practitioner  must  personally  examine  the 
alleged  lunatic  not  more  than  two  days  before  reception.  The  certificate 
may  be  signed  either  before  or  after  the  Order. 

The  following  persons  are  disqualified  for  signing  Certificates  : — The 
Petitioner  ;  the  person  signing  the  Urgency  Order ;  the  Superintendent, 
Proprietor,  or  Medical  Attendant  of  the  Asylum,  Hospital,  or  House  ;  any 
person  interested  in  the  payments  on  account  of  the  Lunatic ;  or  the  husband 
or  wife,  father  or  father-in-law,  mother  or  mother-in-law,  son  or  son-in-law, 
daughter  or  daughter-in-law,  brother  or  brother-in-law,  sister  or  sister-in-law, 
partner  or  assistant  of  any  of  the  foregoing  persons. 

Persons  signing  Medical  Certificates  will  not  be  liable  to  any  civil  or 
criminal  proceedings  if  they  act  in  good  faith  and  with  reasonable  care. 

322 


CERTIFICATE  OF  MEDICAL  PRACTITIONER 


3n 


the  matter  of_ 


(a)  Insert  residence  of  of  (a) 

patient.  ^    ^ 

(6)  County,     city,     or  j^  ^j^g  ry\ 
borough,  as  the  case  may  ^  ' ' 


be. 


(c)  Insert  profession  or  \  ' 

occi,pation,  if  any.  ^^  alleged  lunatic. 

I,  the  undersigned __, 

do  hereby  certify  as  follows  :— 

1.  I  am  a  person  registered  under  the  Medical  Act,  1858, 
and  I  am  in  the  actual  practice  of  the  medical  profession. 

e^i^::^1,i^£         2.  On  the day  of 19 

narM.  of  the  street,   with     •    /^\ 


number  or  name  of  house, 
or    should    there    be    no 

mimber,  the  Christian  and  in  the  (e)_ of  _ 

surname  of  occupier. 


(e)  County,    city,    or  (separately    from    any    other    practitioner)    (/)    I    personally 


borough,  as  the  case  raay  examined  the  said 


^{l^S^u!Zi:S!  and  came  to  the  conclusion  that      he  is  (.j) . 


one  ce'i'tificate  is  required, 

{g)  A  lunatic,  an  idiot,  and  a  proper  person  to  be  taken  charge  of  and  detained  under 

or^a^person  of  unsound  ^^^^  ^^^  treatment. 

3.  I  formed  this  conclusion  on  the  following  grounds,  viz. — 

(Ji)  If  the  same  or  other  ■     t        •        t 

facts  were  observed  previ-      (a.)  Facts  indicating  Insanity  observed  by  myself  at  the  time 
Zi^ZX  t^e^  Of  examination  Q.),  viz.  : 

at  liberty  to  subjoin  them 

in  a  separate  paro.graph.    — ■ 

{i)Thenames and  Chris-  (h.)  Facts  communicated  by  others   (i),   viz 

tian  names  (if  known)  of 


informants  to  be  given, 
with  their  addresses  and 
descriptions. 


4.  The  said. 


appeared  to  me  to  be* in  a  fit  condition 

*  Or  not  to  be.  q£  ijodily   health   to  be  removed   to   an  asylum,   hospital,   or 

(k)  strikeout  this  clause  ^--t    i,„„eg     (h) 
in  case  of  a  patient  whose  licensea   nouse.    (h) 

removal  is  not  p-roposed.  ^    j  ^^^  ^^^^  Certificate  having  fii'st  read  the  section  of  the 

Act  of  Parliament  printed  below. 

(SigneD) 


(0  Insert    full    postal 
address. 


ofW- 


S)ateD  this day  of^ 19 


Extract  from  Section  317  of  the  Lxtnacy  Act,  1890. 

Lunacy  8  ^"^^  person  who  makes  a  wilful  misstatement  of  any  material 

^ ■  fact  in  any  medical  or  other  certificate,  or  in  any  statement  or 

(53  Vict.  c.  5,  ss.  4, 11,  I'eport  of  bodily  or  mental  condition  under  this  Act,  shall  be 

16,  28,  29.)   '     '  guilty  of  a  misdemeanour. 


(SEE    ALSO    NOTES    ON    FLY-LEAF.) 

323 


PETITION  FOR  AN  ORDER  FOR  RECEPTION  OF  A  PRIVATE  PATIENT 


(a) a  justice  of  the 

peace    for ,    or     his 

honovu-  the  judge  of  the 

county  court  of ,  or 

stipendiary     magis- 
trate for . 


5n  tbe  /IDatter  of 

a  person  alleged  to  be  of  unsound  mind. 

To  (a) i 


Ube  petition  ol 


(6)  Full  postal  address,      .  ,, . 

and  rank,  profession,  or  Ol  \0) 

occupation. 

in  the  County  of 


(c)  At  least  twenty-one.        1.  lam (c)  years  of  age. 

2.  I  desire  to  obtain  an  Order  for  the  Reception  of 


(d)  A   lunatic,    or    an 

idiot,  or  a  ]ierson  of  un-  as  (cZ) 

sound  mincl. 

(e)  Asylum,  or  hospital,  in  the  (e) __ of 

orlio\iA^,asthecasemaybe. 

(/)  Insert  a  full  descrip-  situate  at  (/) 

tion    of    the    name    and 
locality   of    the    asylum, 

Jiospital,  or  licensed  house,         3^    j  jg^gj.  g^^^  j^j^g  ga,id 

or  the  Jull  name,  address, 
and    description    of    the 

•person  who  is  to  take  charge  ^^ ^__ 

of  the  patient  as  a  single 

patient.  j  c  1 Q 

(g)  Some  day  witiun  14  on  the  {g) day  Ot 19 

days  before  the  date  of  the 
prcsentationofthepetition. 

(h)  Here  state  the  con-         4.    I  am  the  (h) . of  the 

nection    or    relationship 
with  the  patient.  .  , 

said -^ 

[OP  if  the  Petitioner  is  not  connected  with  or  related  to 

the  Patient,  state  cts  follows .—] 

I  am  not  related  to  or  connected  with  the  said ■ 


The  reasons  why  this  Petition  is  not  presented  by  a  relation 
or  connection  are  as  follows  : — 


Lunacy,  Kos.  1  &  2. 


(53  Viet.  c.  5.  ss.  4,  5,  and 
Sche-i.  II.,  Form  I., 
with  (No.  2)Statement.) 


324 


The  circumstances  under  which  this  Petition  is  presented  hy 
me  are  as  follows  : — 


5.  I  am  not  related  to  or  connected  with  either  of  the  persons 
signing  the  certificates  which  accompany  this  petition  as  (ivhere 
the  petitioner  is  a  man)  husband,  father,  father-in-law,  son,  son- 
in-law,  brother,  brother-in-law,  partner,  or  assistant  {or  where 
the  petitioner  is  a  ivoman),  wife,  mother,  mother-in-law,  daughter, 
daughter-in-law,  sister,  sister-in-law,  partner,  or  assistant. 

6.  I  undertake  to  visit  the  said — _ 

personally,  or  by  some  one  specially  appointed 


by  me,  at  least  once  in  every  six  months  while  under  care  and 
treatment  under  the  Order  to  be  made  on  this  Petition. 

7.  A  Statement  of  Particulars  relating  to  the  said 


If  it  is  the  fact,  add :  8.  The  said- 
has  been  received  in  the  (i) 


accompanies  this  Petition. 


(i)  Asylum,  or  hospital 
nlaj/  b2^^'  "*     **  under  an  Urgency  Order  dated  the. 


The  petitioner  therefore  prays  that  an  Order  may  be  made  in 
accordance  with  the  foregoing  Statement. 


(Jl-)  Full  ChnstioM  and  (SlQltC^)    (fc) 


2)atC  of  Presentation  of  the  Petition,  this day  of 

_19 


325 


STATEMENT  OF  PARTICULARS  referred  to  in  the  Annexed  Petition 

If  any  Particulars  are  not  known,  the  Fact  is  to  be  so  stated 
[Where  the  patient  is  in  the  Petition  described  as  an  idiot,  omit  the  particulars  marked  *] 


The  following  is  a  Statement  of  Particulars  relating  to  the  said_ 

Name  of  Patient,  with  Christian  Name  at  length  -  

Sex  and  Age        ----....  

*  MaiTiedj  Single,  or  Widowed    -         -         - 

*  Rank,  Profession,  or  previous  Occupation  (if  any) 

*  Religious  Persuasion         ------  


Residence  at  or  immediately  previous  to  the  date) 
hereof -         -       j 

*  ^Vhether  First  Attack        ------ 

Age  on  First  Attack    - 

When  and  where  previously  under  Care  and  Treat-) 
ment  as  a  Lunatic,  Idiot,  or  Person  of  Unsound  Mind  j 

*  Duration  of  existing  Attack       ----- 

Supposed  Cause  -         -         -         -         -         -         - 

Whether  subject  to  Epilepsy        -         -         -         -         - 

Whether  Suicidal         -         -         -         -         -         -       -  - 

Whether  Dangerous  to  Others,  and  in  what  way 

Whether  any  near  Relative  has  been  afflicted  with) 
Insanity    --------       j 

Names^  Christian  Names,  and  full  Postal  Addresses  I 
of  one  or  more  Relatives  of  the  Patient    - 

Name  of  the  Person  to  whom  Notice  of  Death  to  be) 
sentj  and  full  Postal  Address,  if  not  already  given/ 

Name  and  full  Postal  Address  of  the  usual  Medical) 
Attendant  of  the  Patient  -         .         .         .       J 

(SiGneb) 


When  the  Petitioner  or  person  signing  an  Urgency  Order  is  not  the  person  who 
signs  the  Statement  add  the  following  particulars  concerning  the  person  who  signs 
the  Statement. 

Name,  with  Christian  Name  at  length 


Rank,  Profession,  or  Occupation  (if  any). 
How  related  to  or  otherwise  connected 
with  the  Patient         ...         ...         ...         


326 


When  neither  Certificate  is  sig^ned  by  the  usual 
Medical  Attendant 


Jj  the  undersigned,  hereby  state  that  it  is  not  practicable  to 
(a)  Name  of  patient,      obtain  a  Certificate  from  the  usual  Medical  Attendant  of  (a) 


for  the  following  reasons,  viz.  : — 


(6)  To  be  signed  by  the  (SlGUCO)    {by 

petitioner. 


A9 


53  Vict.,   c.  5,  s.  7(4). 


When  a  previous  Petition  has  been  dismissed 


J,  the  undersigned,  hereby  state  that  a  former  Petition  for  the 
(a)  Name  of  patient.      Reception  of  {a) — 


(b)  Name    of    asylum,  into  (&)- 
hospital,  licensed  house, 
or  single  charge. 


was  presented  to- 


(c)  Justice  of  the  peace  (c) 
for — ,  or  judge  of  county 
court  (if  — ,  or  stipendiary 
magistrate  for — . 


in  the  month  of ,  19       ,  and  dismissed. 

Herewith  is  a  copy  (furnished  by  the  Commissioners  in 
Lunacy)  of  the  Statement  sent  to  them  of  the  reasons  for  its 
dismissal. 

(Signet))__ 

19 

327 


ORDER  FOR  RECEPTION  OF  A  PRIVATE  PATIENT 

To  be  tmde  by  a  Justice  appointed  under  ttie  Lunacy  Act,  1890, 
Judge  of  County  Coui-ts.  or  Stipendiary  IVIagistrate. 


.  .  ,    ^    ,.      ^  Jf  the  undersigned- 

(a)  A  Justice   for ^^  ° 

specially  appointed  under  ,     .  ,  , 

the  Lunacy  Act,  1890;  or  being  («) 

the  Judge  of  the  County 

Court     of  ,  or     the  . , 

Stipendiary     Magistrate 

^°^        •  upon  the  petition  of_ 


(6)  Address  and  occupa-  of  (*) 
tion. 


in  the  matter  of. 


(c)  Or  an  idiot,  or  per-  a  Lunatic  C')- 
son  of  unsound  mind. 


^accompanied  by  the 


Medical  Certificates  of. 
and 


(d)  Name  of  petitioner,  hereto  annexed,  and  upon  the  undertaking  of  the  said  ('')_ 


^to  visit  the  said 


personally  or  by  some  one  specially  appointed  by  the  said  (**) . 


.once  at  least  in  every  six  months  while 


under  care  and  treatment  under  this  Order,  hereby  authorise 
you  to  receive  the  said 


(e)  Asylum,  or  hospital,  ^^  ^  Patient  in  your  {'I 


or  house,  or  as 
patient, 


HU&  3-  &CClarC  that  I  have  [or  have  not]  personally  seen 

the  said 

before  makina;  this  Order. 


Bateb  this. 


_day  of- 


.19 


(/)  Tobe addressed  to  the 
medical  supe-nntendent  of 
the  asvlv/M  or  hospital,  or 
to  the  resident  licensee  of  the 
house  in  xohich  the  patient  m  /  /•>, 
is  to  be  placed,  or  to  the  -"-"  \J  )- 
person  in  charge  of  a 
single  patient. 

Lunacy  3. 


(Staneb)  («)- 


A  Justice  for  appointed 

under  the  above-mentioned  Act  [or  the  Judge 
of  the  County  Court  of 
or  a  Stij^endiary  Magistrate']. 


328 


Form  of  Urgrency  Order  for  the  Reception  of  a 

Private  Patient,  with  Medical  Certificate  and 

Statement  accompanying  Urg-ency  Order 


jf  the  undersigned,  being  a  Person  Twenty-one  years  of  age, 


(a)  House,  or  hospital,  ,i       •  ,  •  -o  j.-      j.  •    j.  /n\ 

or  asvium,  or  as  a  single  hereby  authorize  you  to  receive  as  a  Patient  into  your  (")_ 
patient. 


(6)  Name  of  Patient.        ('')  _ 


(c)  Lunatic,  or  an  idiot, 
or  a  person  of  unsound  as  a  (")- 
mind. 


.whom  I  last  saw  at 


(d)  Some dayioitUn  two  on  the  ('^)- 
days  hefcre  the  date  of  the 
order. 


,day  of _ 


-19 


%  am  not  related  to  or  connected  with  the  Person  signing  the 
Certificate  which  accompanies  this  Order  in  any  of  the  ways 

Subjoined  [fjr  annexed]  hereto  is 


(e)  Husband,  wife,  .  i  •       i       -n/r        •     / 

father,  father-in-law,  mentioned  m  the  Margin. ( 

mother,      mother-in-law, 

son,  son-in-law,  daiighter,       r-.,,  ./■t-..-t  ij_-        j.j.i  -i 

danKhter-in-iaw,  brother,  a  Statement  of  Particulars  relating  to  the  said 
brother-in-law,  sister, 
sister-ill-law,  partner,  or 
assistant. 

(Si5ne^) 

[//  not  the  husband  or 
wife,  or  a  relative  of  the  Name  and   Christian  Name\ 

Patient,  the  per  son  signing  ,  ,  1 

to  state  as  briejiy  as  possi-       at  length    -  -  -  -J 

ble: — 1.   Why  the  order  is 

not  signed,  by  the  husband 

or  wife  or  a  relative  of  the  -n      i      -n      /•      •  /-\  \ 

Pntitnt.  2.  Eisorhercon.  Hank,  Profession  or  Occupa-\ 

nection  with  the  Patient,        Hon  (if  anil)        -  -  -  i 

and     the     circumstances  \J         J I 

under   which  he   or    she 
signs.] 


Full  Postal  Address 


(j)  Superintendent     of 

the  asylum, hos 

pital  or  resident  h'censee 
of  the ho  se  [describ- 
ing the  asylum,  hospital, 
or  house  by  situation  and 
name,  or  to  the  person  in 
charge  of  a  single  patient.] 

Lunacy,  4  and  2. 


(53  Vict.  c.  5,  s.  11.) 


How  related  to  or  connected^ 
tlllhos-      tvith  the  Patient        -         -J 


Bateb  this 


To{f)^ 


.day  of_ 


.19 


329 


STATEMENT  OF  PARTICULARS  referred  to  in  the  Annexed  Order 

If  any  Particulars  are  not  knotmi,  the  Fact  is  to  be  so  stated 

[Where  the  Patient  is  in  the  Petition  or  Order  described  as  an  idiot,  omit 
the  particulars  marked  *] 


The  following  is  a  Statement  of  Particulars  relating  to  the  said- 
Name  of  Patient,  with  Christian  Name  at  length  -  

Sex  and  Age         -------- 

*  Married,  Single,  or  Widowed    ----- 

*  Rank,  Profession,  or  previous  Occupation  (if  any)    - 

*  Religious  Persuasion         -         -         -         -         -         - 

Residence  at  or  immediately  previous  to  the  date) 
hereof    -- 'J 


*  Whether  First  Attack        ------ 

Age  on  First  Attack     ------- 

When  and  where  previously  under  Care  and  Treat- "^ 
ment  as  a  Lunatic,  Idiot,  or  person  of  Unsound  Mind/ 

*  Duration  of  existing  Attack       ----- 

Supposed  Cause  -------- 

Whether  subject  to  Epilepsy        ----- 

Whether  Suicidal         ------- 

Whether  Dangerous  to  Others,  and  in  what  way 

Whether  any  near  Relative  has  been  afflicted  withl 
Insanity         .......         .j 

Names,  Christian  Names,  and  full  Postal  Addresses  I 
of  one  or  more  Relatives  of  the  Patient  -         -  j 

Name  of  the  Person  to  whom  Notice  of  Death  to  he\ 
sent,  and  full  Postal  Address,  if  not  already  given/ 

Name  and  full  Postal  Address  of  the  usual  Medicals 
Attendant  of  the  Patient        -         -         -         -         -/ 

(Signe^) 


When  the  Petitioner  or  person  signing  an  Urgency  Order  is  not  the  person  who 
signs  the  Statement  add  the  following  particulars  concerning  the  person  who  signs 
the  Statement. 


Name,  with  Christian  Name  at  length- 


Rank,  Profession,  or  Occupation  (if  any)- 
How  related  to  or  otherwise  connected 
with  the  Patient         ...  ...  ...         


330 


CERTIFICATE  OF  MEDICAL  PRACTITIONER 


jU  the  matter  of. 


(a)    Insert  residence  of  Oi  (ct)- 
Patient. 


(b)     County,    city,    or  in  the  (b) of- 

Dorough  as  the  case  viay  ^  ' 

he. 

(e)  Insert  Profession  or  \^) 

Occupation,  if  any. 


an  alleged  lunatic. 
I,  the  undersigned- 


do  hereby  certify  as  follows  : 

1.  I  am  a  person  registered  under  the  Medical  Act,  1858, 
and  I  am  in  the  actual  practice  of  the  medical  profession. 

2.  On  the day  of 19 

(d)  Insert  the  place  of  ^^  W — 

examination,    giving    the 

name   of  the  street,   with 

number  orname  of  house,  in  the  (e) of 

or    should    there    be    no 
number,  the  Christian  and 

Surname  of  Occupier.        j  personally  examined  the  said . 

(e)  County,    city,    or 
borough,  as  the  case  tnay 

^^-  and  came  to  the  conclusion  that      he  is  (/) 

(/)  A  lunatic,  an  idiot, 
or  a  person  of  unsound  and  a  proper  person  to  be  taken  charge  of  and  detained  under 
mind.  r     sr        i. 

care  and  treatment. 

3.  I  formed   this    conclusion   on   the  following    grounds. 


VIZ. 


(<,)  If  the  same  or  other  («)  ^acts  indicating  Insanity  observed  by  myself  at  the 

■vious  to  the  tirne  of^'the  time  of  examination  {g)  viz.  : 

examination,  the  certifier 


is  at  liberty  to  subjoin  them 
in  a  separate  paragraph. 


(h)  The  Names  and  Chris- 
tian Names  (if  known)  of 


informants  to  be  given,  (b.)  Facts  communicated  by  others  (/i)  viz. 

2oith  their  addresses  and 
descriptions. 

Lunacy  Nos.  8  &  9.  - — ^ ^ 


(53  Vict.  c.  5,  ss.  11. 
28,  29,  32  &  33.) 


331 


53  Vict.  c.  5. 

n^I^^:^i;e      [(^)  STATEMENT  ACCOMPANYING  URGENCY  ORDER 

added  here.     Font  No.  9. 


J   CCrttt^  that  it  is  expedient  for  the  welfare  of  the  said 
_[o)'  for  the  public  safety,  as 


the  case  may  be]  that  the  said_ 


should  be  forthwith  placed  under  care  and  treatment. 


My  reasons  for  this  conclusion  are  as  follows  : — _ 


4.  The  said_ 


appeared  to  me  to  be  [or  not  to  be]  in  a  fit  condition  of  bodily 
(k)  Strike  oiu  this  clause  health  to  be  removed  to  an  asylum,  hospital,  or  licensed  house,  (k) 

in  case  of  a pnvate  patient 
whose  removal  is  not  pro- 

^"^^ "  5.  I  give  this  certificate  having  first  read  the  section  of  the 

Act  of  Parliament  printed  below. 


2)ate&  this day  of 

One  thousand  nine  hundred  and 


(Si^neb)- 


(0  Insert     full    Postal  of  (H- 

Address.  ^  ^ 


332 


3, 


ORDER  FOR  RECEPTION  OF  A  PAUPER  LONATIC,  OR  LUNATIC  WANDERING  AT  URGE 

— — ^having  called 


to  my  assistance 
of 


and  being  satisfied  that. 
of 


-a  duly  qualified  medical  practitioner, 


— ^ — is  a  pauper  in  receipt  of  relief, 

[or  in  such  circumstances  as  to  require  relief  for  h         proper  care  and  maintenance] 

and  that  the  said ^ig  ^ 

lunatic  or  a  person  of  unsound  mind  and  a  proper  person  to  be  taken  charge  of  and 

detained  under  care  and  treatment,  or  that 

is  a  lunatic,  and  was  wandering  at  large,  and  is  a  proper  person  to  be  taken  charge 
of  and  detained  under  care  and  treatment,  hereby  direct  you  to  receive  the  said 
as  a  patient  into  your  Asylum.  Subjoined  is  a  statement  of  particulars  respectino- 
the  said 

(Signet)) .- 

(A  Justice  of  the  Peace  Jor  the  County  of) 

(Dateb)  the day  of 19 . 

To  the  Superinte'iident  of  the  Asylum  for  the  County  of _^_ 


STATEMENT  OF  PARTICULARS  REFERRED  TO  IN  THE  ABOVE  ORDER 

If  any  particulars  are  not  known,  the  fact  is  to  he  so  stated 
[Where  the  Patient  is  in  the  Order  described  as  an  idiot,  omit  the  particulars  marked*] 

The  following  is  a  Statement  of  Particulars  relating  to  the  said 

Name  of  Patient,  with  Christian  Name  at  length 

Sex  and  Age        ....--- 

*  Married,  Single  or  Widowed     -    •     -         -         -         - 

*  Rank,  Profession,  or  previous  Occupation  (if  any)    . ■. . 

*  Religious  Persuasion 

Residence  at  or  immediately  previous  to  the  date/ ■ 

hereof      --------        \  

*  Whether  first  attack 

Age  on  first  attack 

When  and  where  previously  under  Care  and  Treat- 1  — 

ment  as  a  Lunatic,  Idiot,  or  Person  of  Unsound  Mind  [ 

*  Duration  of  existing  Attack       -         -         - 

Supposed  Cause  -         -         -         -         -         -         -  

Whether  subject  to  Epilepsy       -         -         - 

Whether  Suicidal 

Whether  Dangerous  to  Others,  and  in  what  way 

Whether  any  near  Relative  has  been  afflicted  with  f  " 

Insanity  --------\ 

Union  to  which  Lunatic  is  chargeable  -         - 

Names,  Christian  Names,  and  full  Postal  Addresses  f  - 

of  one  or  more  relatives  of  the  Patient     -         -        \  ~ 
Name  of  the  Person  to  whom  Notice  of  Death  to  be  j 

sent,  and  full  Postal  Address,  if  not  already  given  \ 

(Signet)) . — 

Relieving  Officer  of  the Union 

H)atet))  the ^ day  of 19 

333 


CERTIFICATE  OF  MEDICAL  PRACTITIONER 


jTi  the  matter  of_ 
of  


in  the  County  of. 


an  alleged  lunatic  : 

I,  the  undersigned . 

do  hereby  certify  as  follows  : 

1.  I  am  a  person  registered  under  the  Medical  Act,  1858,  and  I  am  in  the  actual 
practice  of  the  medical  profession. 

2.  On  the day  of 19 

at- 

in  the  County  of 1  personally  examined  the  said 


and  came  to  the  conclusion  that     he  is  a  lunatic  or  a  person  of  unsound  mind,  and 
a  proper  person  to  be  taken  charge  of  and  detained  under  care  and  treatment. 

3.  I  formed  this  conclusion  on  the  following  grounds,  viz.  : — 

(a)  Facts  indicating  insanity  observed  by  myself  at  the  time  of  examination, 


(b)  Facts  communicated  by  others,  viz.  :- 


4.  The  said_ 


appeared  to  me to  be  in  a  fit  condition  of  bodily  health  to  be  removed  to 

an  asylum,  hospital,  or  licensed  house. 

5.  I  give  this  certificate  having  first  read  the  section  of  the  Act  of  Parliament 
printed  below. 

(SiGne&) 


of_ 


(BateC))  this^ day  of . 19_ 

334 


INDEX 


Abdomisai,     disease     and      insanity, 

229 
Absence,  leave  of,  274 
Abulia,  63,  223 
Achromatolysis,  242 
Achromatoplasm,  24 
Acrophobia,  224 
Action,  automatic,  62 

habitual,  62 

impulsive,  62 

instinctive,  56 

reflex,  56 

voluntary,  61 

Acute  delirium,  129 

dementia,  132 

AdaUn  in  treatment,  308 
Adolescence,  94,  156,  206 
Adolescent  general  paralysis,  180 
Esthetic  sentiments,  53 
ASection,  47 
Affects,  52 

transference  of,  52,  225 

After-care  of  patients,  318 

association,  318 

After-images,  37 

sensations,  37 

Age,  incidence  of,  1 

in  prognosis,  257 

Agnosia,  36 

Agoraphobia,  224 

Alcohol  and  insanity,  93,  186 

in  treatment,  300 

Alcoholic  insanity,  191 
Alcohohsm,  acute,  187 

chronic,  191 

Alexia,  36 

Alternating  insanity,  123 
Amaurotic  family  idiocy,  144 
Amentia,  142 

brain  in,  150,  239 

Amnesia,  29 

Amylene  hydrate  in  treatment,  307 
Ansesthesia,  cutaneous,  34,  126 
Antesthetics  in  the  insane,  311 
Anergic  stupor,  133 
Anticipation,  89 
Aphasia,  65,  72,  279 
Aphonia,  hysterical,  218 
Apperception,  35,  67 


335 


Apraxia,  65 
Arachnoid,  Pia-,  250 
ArgyU-Robertson  pupU,  174 
Art,  influence  of,  317 
Arteries  of  the  brain,  247 
Arterio -sclerosis  and  insanity,  166 
Artificial  feeding,  300 
Association  areas,  28 

fibres,  26 

laws  of,  41 

of  ideas,  40 

Asylums,  criminal,  272,  283 

private,  272,  296 

pubUc,  272,  295 

wards  in,  103 

Atavism,  86 
Attention,  67 

disorders  of,  68 

laws  of,  67 

physical  basis  of,  67 

varieties  of,  67 

Automatic  attention,  67 

movements  in  general  paralysis, 

178 

obedience,  203 

Automatism,  63,  211,  212 
Axon,  23 

Babinski's  sign,  83 
Baths,  298 

Bedsores,  prevention  of,  303 
Belief,  41,  52 
BeU's  disease,  130 
Belladonna  dehrium,  199 
Bethlem  Hospital,  history  of,  8 
Betz  cells,  25,  241 
Binet-Simon  test,  153 
Bladder,  treatment  of,  302 
Blood  in  the  insane,  248 

pressure  in  insanity,  112, 121,  228, 

249 
Board  of  control,  277 
Boarders,  voluntary,  272 
Boarding-out  system,  319 
Bodily  disease  and  insanity,  232 
Borderhne  cases,  140,  223 
Bowels,  treatment  of,  302 
Brain,  arteries  of,  247 
chemistry  of,  239 


336 


INDEX 


Brain  fever,  130 

Brain,  general  morbid  changes  in,  235 

in  amentia,  150,  239 

in  dementia,  169,  238 

in  general  paralysis,  181,  238 

■  membranes  of,  250 

venous  sinuses  of,  248 

weight  of,  237 

Bright's  disease  and  insanity,  228 
Bromides  in  treatment,  307 

stupor  from,  200 

Bromidia  in  treatment,  306 
Business  anxiety,  97 

Calculating  imbeciles,  29,  150 
Cannabis  indica  insanity,  199 
Care  of  chronic  insane,  319 

of  mental  defectives,  320 

Catalepsy,  133,  158 

Causation,  general,  84 

Cehbacy,  95,  289 

Central  authority  for  lunacy  and  mental 

deficiency,  277 
Cephahc  index,  253 
Cerebral  circulation,  249 

locaUsation,  27 

Cerebrospinal  fluid,  245 
Certificates  of  sanity,  271 
Certification  for   care   and  treatment, 

262,  294 

of  pauper  patients,  264,  334 

of  private  patients,  265,  323 

Chancery  patients,  271 
Character,  56 
Chemical  restraint,  305 
Chemistry  of  brain,  239 
Childbirth  and  insanity,  95,  201 
.  Children,  insanity  in,  205 

upbringing  of  nervous,  287 

Chloralamide  in  treatment,  306 

Chloral  in  treatment,  306 

Chlorahsm,  198 

Chloroform  habit,  200 

ChoUn,  183,  245 

Chorea  and  insanity,  230 

Chromatylosis,  242 

Chromatoplasm,  24 

Church  services,  97,  289,  317 

Circular  insanity,  123 

Circulation,  cerebral,  249 

Civil  habihty,  281 

Civil  state,  incidence  of,  1 

Civihsation,  influence  of,  2 

Classification  of  insanity,  99 

Claustrophobia,  224 

Chmacteric  and  insanity,  95,  207 

Cocainism,  198 

Codes  in  paranoia,  65 

Ccenffisthesis,  33 

Cognition,  69 

Colitis,  ulcerative,  232,  309,  310 


Collapse  delirium,  130 

Colony  system,  215,  319 

Commissioners,  277 

Commissural  fibres,  26 

Committee  of  person  and  estate,  271 

Communicated  insanity,  141 

Complexes,  40,  316 

Conation,  57,  61,  67 

Concept,  40 

Conception,  40 

Concussion,  233 

Conditions  resembling  insanity,  71 

Conduct,  55 

Conflict,  40 

Confusion,  42 

Confusional  insanity,  125 

Consanguinity,  89,  143 

Conscience,  52 

Consciousness,  16 

disorders  of,  18 

• ■  double,  18 

fringe  of,  17 

object,  17 

■  physical  basis  of,  22 

self,  17 

spht,  18 

— — •  subject,  16 
Constipation,  303 
Contact  with  the  insane,  98 
Continuation  reports,  274 
Contracts,  281 
Contracture,  178,  217 
Coprolalia,  63 
Coprophobia,  224 

Correspondence,  patients',  274,  298 
Cortex,  layers  of,  25 

structure  of,  25 

Cortical  atrophy,  167 

County  asylum,  vide  public  asylum. 

Cranium,  shape  and  size  of,  252 

Cretinism,  147,  229 

Cretinoids,  230 

Criminal,  54,  153,  155,  284 

Criminal  asylums,  272,  283 

insane,  265,  283,  320 

oflences  in  the  insane,  283,  284 

— —  responsibihty,  282 
Criminality,  76 
Cystitis,  303 

Deafness,  34 

Deaf  mutes,  147,  149 

Death  rate  in  insanity,  4,  232 

Decortication,  251 

Definition  of  feeble-mindedness,  152 

■  idiocy,  142 

imbecility,  142 

insanity,  73 

mental  defectives,  275 

mind,  14 

moral  imbecihty,  153 


INDEX 


337 


Definition  of  psychology,  14 
Degeneracy,  stigmata  of,   88,   91,  137, 

147,  210,  254 
Degenerates,  moral,  53 
Deiter's  cells,  244 
Delirium,  71,  129 

acute,  129 

tremens,  189 

Delusional  insanity,  systematised,  136 

stupor,  134 

Delusions,  43 

fixed,  45,  120 

of  the  sane,  44 

treatment  of,  314 

Dementia,  156 

acute,  132 

•  brain,  in,  169,  238 

epileptic,  212 

organic,  166 

• paralytica,  171 

paranoides,  158 

partial,  163 

prsecox,  156 

^ varieties  of,  157 

primary,  156 

—  secondary,  163 

senile,  167 

Dendron,  23 

Desertion  as  a  cause,  97,  201 

Desire,  57 

Dexterities,  63 

Diabetes  and  insanity,  227 

Diagnosis  of  insanity,  71 

Diagram  of  mental  processes,  69 

Diathesis,  insane,  88 

Diet,  299 

Dipsomania,  194,  224 

Direct  stress,  92 

Disorders  of  attention,  68 

consciousness,  18 

emotion,  51 

feeling,  48 

handwriting,  65 

ideation,  42 

instincts,  59 

memory,  29 

perception,  36 

sensation,  34 

sentiments,  53 

sleep,  20 

speech,  65 

voHtion,  63 

Disorientation,  36,  126,  130 
Disseminated    sclerosis    and    insanity. 

232 
Dissociation,  37,  44 
Distraction,  68 
Divorce  and  insanity,  290 
Domestic  sorrow,  97 
Double-consciousness.  212,  218 
Doubt,  53,  63 


Doute,  foHe  du,  223 
Dreams,  20,  315 
Drug  states,  72 
Drunkenness,  72,  187 
Dualism,  14 
Dura  mater,  251 
Duty,  52 

Dysentery,  asylum,  vide  CoHtis,  Ulcera- 
tive. 
Dyspraxia,  65 

Ear,  anomalies  of,  253 
insane,  254,  312 

Eccentricity,  72 

Eccentrics,  140 

Echolalia,  43,  160 

Echopraxia,  65,  160 

Education,  faultv,  97 

Ego,  16 

Egocentrics,  139 

Electrical  variation  in  nerves,  237 

Electricity,  299 

Emotion,  48 

Emotion  disorders  of,  51 

expression  of,  49 

physical  basis  of,  50 

Endothehal  cells,  245 

Enteric  fever  and  insanity,  227 

Environment,  76,  317 

Environmental  stress,  96 

Ependyma,  frosted,  251 

Epicritic  sensation,  33 

Epilepsie  larvee,  212 

Epilepsy  and  insanity,  96,  209 

Epochal  insanity,  205 

Equivalents,  epileptic,  212 

Escape,  274 

Ether  habit,  200 

Etiology  of  insanity,  84 

Eugenics,  3,  291 

Evolution  of  lunacy  legislation,  10 

mind,  15 

Examination  of  patient,  guide  to,  79 

mental  state,  80 

physical  condition,  82 

Exercise  in  insanity,  316 
Exhaustion  insanity,  125 
Exophthalmic  goitre  and  insanity,  230 
Expression  of  emotion,  49 
Eye  colour,  transmission  of,  86 

Eacihtv,  63,  156,  279 

Faddists,  140 

Fatigue,  18,  19,  24,  25,  125,  220,  243 

Fears,  223,  224 

Feeble-mindedness,  congenital,  152 

Feeding,  forcible,  300 

rertal,  301 

Feeling,  47 

■ •  disorders  of,  48 

physical  substratum  of,  47 


338 


INDEX 


Feigned  insanity,  72,  283 
Fits,  alcoholic,  192 
Fits,  epileptic,  210 

hysterical,  218 

in  general  paralysis,  175 

Fixed  delusion,  120 

ideas,  42,  223 

Flexibilitas  cerea,  133,  158 
Flight  of  ideas,  42,  116   . 
FoUe  a  deux,  141 

circulaire,  123 

du  doute,  223 

du  toucher,  65 

Forcible  feeding,  300 
Formalin,  hardening  by,  236 
Free  association,  315 

will,  61 

Fright  as  a  cause,  98 

Furor  epileptic,  212 

Freud's  psychology,  52,  58,  217,  225,315 

Gemmules,  23 
General  paralysis,  171 

brain  in,  181,  238 

etiology  of,  171 

pathology  of,  181 

Genius,  41,  90 
GHa  cells,  changes  in,  244 
GlobuHn,  183,  246 
Globus  hystericus,  217 
Glycosuria  and  insanity,  227 
Goitre  and  insanity,  147 

exophthalmic,  and  insanity,  230 

Gout  and  insanity,  227 
Grand  mal,  210 

Gross  brain  disease,  and  insanity,  94, 
166 

Habeas  corpus,  263 
Habit,  62 

neural,  29 

Habits,  bad  and  insane,  64 
Hsematoma  auris,  254,  312 
Hsematoporphyrinuria,  200,  307 
Hallucinations,  37 

auditory,  38 

of  pain,  39 

of  smell,  39 

of  taste,  38 

—  of  temperature,  39 

—  of  touch,  39 

—  organic,  39 

secondary,  37 

visceral,  39 

visual,  38 

Hallucinatory  insanity,  126 
Handwriting,  disorders  of,  65 

in  the  insane,  66,  192 

Hearing,  32 

Heart  disease  and  insanity,  229 
Hebephrenia,  158 


Heredity,  85,  90 
Hesitating  insanity,  223 
History,  patients',  80 
Homicide,  64,  141,  188,  211,  224 
Homosexuality,  61 
Hormones,  93,  243 
Hospitals  for  the  insane,  103 

registered,  272,  295 

Hyoscine  in  treatment,  308 

Hyoscyamine  in  treatment,  308 

Hyper-attention,  68 

HyperbuUa,  63 

Hypermnesia,  29 

Hypnosis,  20 

Hypnotics,  306 

Hypnotism  in  insanity,  316 

Hypochondriasis,  45,  72,  110,  139 

Hypomania,  118 

Hypotonia,  134 

Hysteria  and  insanity,  72,  216 

Hysterical  insanity,  217 

Icebags,  treatment  by,  299 
Ideas,  39 

absence  of,  42,  65 

acceleration  of,  42 

association  of,  40 

fixed,  42,  223 

imperative,  42.  63,  223 

obsessional,  42 

of  reference,  138 

retardation  of,  42 

Ideation,  39 

— —  disorders  of,  42 

physical  basis  of,  42 

Identity,  16 

delusions  of,  44 

Idiocy,  142 

definition  of,  142 

varieties  of,  144 

Idiopathic  insanity,  105 
Illegitimacy,  95,  142,  201 
lU-treatment  of  patients,  274 
Illusions,  36,  38 

of  memory,  29,  192 

Imagination,  41,  53 
Imbecihty,  150 

definition  of,  142 

moral,  153 

Imitation,  98 

Imperative  ideas,  42,  63,  223 
Imperception,  36,  126 
Impotence,  96,  110,  140 
Impulse,  62 

morbid,  224 

Impulsive  insanity,  223 
Inattention,  68 
Incidence  of  age,  1 

civil  state,  1 

insanity,  1 

sex,  1 


INDEX 


339 


Incipient  insanity,  78 
Incoherence,  42 
Increase  of  insanity,  3 
Indecision,  63,  223,  224 
Indemnity,  letter  ot,  2b3,  zyrf 
Indirect  stress,  94 
Induced  insanity,  141 
Inebriates  Act,  the,  278 
Inebriation,  alcoholic,  (2,  i»7 
Infantilism,  144 
Infections  as  causes,  94 
Influenza,  93,  226 
Inheritance,  laws  of,  86 
Inquisition,  271 
Insane  diathesis,  88 

ear,  vide  Haematoma  auris 

habits,  64 

heredity,  90 

Insanity,  alcohol  and,  93,  186,  300 

alcoholic,  191 

alternating,  123 

causation  of,  84 

childbirth  and,  201 

classification  of,  99 

communicated,  141 

conditions  resembhng,  71 

. confusional,  125 

death  rate  in,  4,  232 

definitions  of,  73 

. diagnosis  of,  71 

epilepsy  and,  96,  209 

"    epochal,  205 

etiology  of,  84 

. feigned,  72,  283 

hallucinatory,  126 

■  hesitating,  223 

hysteria  and,  216 

impulsive,  223 

incidence  of,  1 

incipient,  78 

^ increase  of,  3 

. induced,  141 

intermittent,  105 

lactational,  203 

moral,  154,  284 

neurasthenia  and,  220 

obsessional,  223 

of  pregnancy,  201 

partial,  75 

pathology  of,  235 

post-feb7ile,  226 

post  operative,  l^b,  zsa 

potential,  90 

prognosis  in,  25b 

psychasthenia  and,  223 

puerperal,  202 

recovery  rate  of,  4 

systematised  delusional,  i3b 

.  traumatic,  233 

. treatment  of,  286 

vohtional,  223 

z  2 


Insight,  45,  78  .      .  -,       «    . 

Insolation    and    insamty,     vide     bun- 
stroke. 
Insomnia,  20,  94 

treatment  of,  304 

Instincts,  57 

. development  of,  58 

disorders  of,  59 

. physical  basis  of,  59 

Institution  care,  295 

selection  of,  297 

Intellect,  39  _ 

Intellectual  sentiments,  o2 

Interactionism,  14 

Interest,  67 

Intermittent  insanity,  lOo 

Intestinal  antiseptics,  309 

Intoxication,  alcohoHc,  72,  18/ 

psychoses,  125 

drug,  198 

Introspection,  14  _ 

Ireland,  lunacy  procedure  in,  Al^ 

James's  theorv  of  emotions,  50 
Jealousy,  49,  138,  192 
Jofiroy's  sign,  177  __ 
Judge'^in  lunacy,  271 
Judgment,  41 

Judicial  authority,  268,  Zib 
Just -noticeable  sensations,  31 

Justice,  52 

orderof,  268,  2/0,328 

Juvenile  general  paralysis,  180 

Katatonia,  158 
Katatonic  stupor,  158 
Kidney,  movable,  229 
Kinffisthetic  sensations,  33 
Kleptomania,  224,  284 
Korssakow  s  syndrome,  191,  D- 

Lactational  insanity,  203 
Language,  55 

mechanism,  64 

Laws  of  association,  41 

attention,  67 

inheritance,  86 

Lead  and  insanity,  93,  126    199 
Legal  duties  of  person  m  charge,  _/J 

^  relations  of  insanity,  262 

responsibihty,  281,  282 

Lec^islation,  evolution  of  lunacy,  10 

Letters,  patients',  274,  298 

Leucocytosis,  246 

Licensed  houses,  vide  Private  Asylums. 

Libel  by  the  insane,  281 

Lipoids,  239  . 

Local  signs  in  space  perception,  6o 

Localisation,  cerebral,  27 

Love,  as  a  cause,^97 

passion  of,  57 


340 


INDEX 


Lucid  intervals  in  insanity.  75,  124,  260, 

280 
Lumbar  puncture,  in  insanity,  246 

operation  of.  312 

Lunacy  Act,  263 

penalties  and  protection  of,  263 

legislation,  evolution  of,  10 

Lung  disease  and  insanitv,  229,  232,  311 
Lymphoc3i:osis,  183,  246,  312 

Malaria  and  insanity,  227 
Malingering,  234,  vide  Feigned  Insanity 
Mania,  114 

acute  delirious,  130 

a  potii,  188 

varieties  of,  118 

Maniacal-depressive  insanity,  105 
Mannerisms,  160 
Marriage  and  insanity,  289 

of  cousins,  89 

Masked  epilepsy,  212 
Massage,  113,  135,  219,  222,  298 
Mast  cells,  182,  244 
Masters  in  lunacj%  271 
Masturbation,  60,  95,  288 

treatment  of,  303 

Mattoids,  140 
Maudsley  Hospital,  295 
Meaning,  40 

Mechanical  restraint,  10,  274,  298 
Medical  certificates,  266,  323 
Medicinal  treatment  of  insanity,  308 
Medinal  in  treatment,  307 
Melancholia,  105 

varieties  of,  108 

Membranes  of  the  brain,  250 
Memory,  28 

disorders  of,  29 

physical  basis  of,  29 

Mendelism,  86 

Menopause,  95,  207 

Menstruation  in  insanity,  204,  260,  309 

Mental  caKbre,  41 

defectives,  care  of,  320 

• definition  of,  275 

deficiency,  142,  275 

Deficiency  Act,  the,  275 

state,  examination  of,  80 

stress,  96 

wrecks,  77 

MicrocephaUc  idiocy,  144 

Mind,  14 

Mongolian  idiocy,  144 

Monism,  15 

Monomania,  136,  139 

Mood,  48 

Moral  degeneracy,  153 

imbecility,  153,  284 

insanity,  154,  284 

sentiments,  52 

Morality,  52 


Morphia  in  treatment,  308 
Morphinism,  195 
Motor  area,  63 
Mott's  pedigrees,  89 
Movements,  development  of,  58 
Mueller's  doctrine,  31 
Muscular  element  of  thought,  68 
Music,  influence  of,  317 
Mutism,  42,  65,  87,  160,  218 
Mysophobia,  224 
Myxcedema  and  insanity,  229 

Narcolepsy,  20 
Nasal  tube  feeding,  302 
Negativism,  160 
Neurasthenia  and  insanity,  220 

traumatic,  217,  221,  234 

Neurin,  24 
Neuron,  22,  240 
Neuroses  and  insanity,  102 
Night  terrors,  20,  287 
Nissl  bodies,  24,  242 
Nonne-Apelt  test,  246 
Nosophobia,  224 
NuUity  of  marriage,  281 
Nyctophobia,  224 

Obsession,  42,  63,  223 
Obsessional  insanity,  223 
Occupation,  97,  289,  316 

neuroses,  232 

Ocular  signs  of  general  paralysis,  174 
Oesophageal  tube  feeding,  301 
Operations  on  the  insane,  311 
Opium  habit,  196 

in  treatment,  308 

Opsonic  work,  249 

Order,  Lunacy  Reception,  268,  328 

Mental  Deficiency  Reception,  275 

Summary  Reception,  264,  333 

Three-day,  264 

Urgency,  269,  329 

Organic  brain  disease,  166 

dementia,  166 

sensation,  33 

Orientation,  35 
Othsematoma,  254,  312 
Overwork  as  a  cause,  97 

Paccluonian  bodies,  252 
Pachymeningitis    hsemorrhagica,     251, 

252 
Palate,  deformities  of,  253 
Paraldehyde  in  treatment,  306 

toxic  effects  of,  200 

Parallelism,  14 

Paralysis  agitans  and  insanity,  230 

general,  171 

brain  in,  238 

etiology  of,  171 

pathology  of,  181 


INDEX 


341 


Paralysis,  general,  pseudo-,  180,  191 
Paralytic  dementia,  171 
Paramnesia,  29,  192 
Paranoia,  136 

pseudo-,  191 

Para-syphilis,  182 
Paresis,  general,  171 
Parole,  318 
Partial  dementia,  163 

insanity,  75 

Passion,  48 

Pathology  of  insanity,  235 
Pellagra  and  insanity,  230 
Pelvic  disease  and  insanity,  229 
Perception,  35 

centres,  28 

disorders  of,  36 

of  space  and  time,  35 

physical  substrata  for,  36 

Periodic  insanity,  123 
Perseveration,  30 
Personality,  16,  137,  139 

alternating  or  double,  18,  44,  212, 

218 
Petit  mal,  210 
Petition,  lunacy,  266,  324 
Phobias,  63,  224 
Phthisis  in  insanity,  228,  232 
Physical  basis  of  attention,  67 

consciousness,  22 

dreams,  20 

emotion,  50 

feeling,  47 

hypnosis,  22 

ideation,  42 

instincts,  59 

memory,  29 

perception,  36 

sensation,  33 

sentiments,  53 

sleep,  19 

will,  62 

Physical  examination  of  patient,  82 
Pia-arachnoid,  250 
Pineal  body,  252 
Pituitary  gland,  252 
Plasma  cells,  182,  244,  246,  251 
Polyneuritic  psychosis,  191 
Porencephaly,  151,  239 
Position,  sense  of,  33 
Post-epileptic  automatism,  211 
Post-operative  insanity,  126,  233 
Post-paroxysmal  epileptic  insanity,  211 
Potential  insanity,  90 

•  suicide,  110 

Precocious  dementia,  156 
Pregnancy,  insanity  of,  201 
Preparoxysmal  epileptic  insanity,  211 
Presbyophrenia,  169 
Primary  dementia,  156 
Prisoner,  examination  of,  283 


Private  asylums,  272,  296 
Privation  as  a  cause,  94 
Prognathism,  253 
Prognosis,  the  elements  of,  256 
Projection  areas,  28 

fibres,  26 

Protopathic  sensation,  33 
Pseudo-general  paralysis,  180,  191 

paranoia,  191 

Psychasthenia  and  insanity,  223 
Psycho-analysis,  56,  315 

therapeutics,  313 

Psychiatry,  13 
Psychology,  14 

objective,  14 

subjective,  14 

Puberty,  94,  205,  288 
Pubhc  asylums,  272,  295 
Puerperal  insanity,  202 
Pupils  in  general  paralysis,  174 
Pyromania,  224 

Racial  differences,  2,  70 

Reaction,  mental,  80 

time,  56,  316 

Reasoning,  42 

Recapture,  274 

Reception  Orders,  Lunacy,  268,  328 

Mental  Deficiency,  275 

Receiver,  appointment  of,  270 

Recognition,  35 

Recovery  rate  of  insanity,  4 

Rectal  feeding,  301 

Recurrent  mania,  120 

melanchoUa,  108 

sensations.  37 

Re-education,  220,  225,  316 

Reference,  ideas  of,  138 

Reflex  action,  56 

Reflexes,  83 

Refusal  of  food,  60,  300 

Registered  hospitals,  272,  295 

Religion  and  in  anity,  97,  139,  289,  317 

Remissions  in  general  paralysis,  185, 
259 

Resistive  stupor,  134 

Responsibility,  civil,  281 

criminal,  282 

Rest  cure,  297 

Restraint,  vide  mechanical,  and  chemi- 
cal 

Retrospection,  14 

Rheumatic  fever  and  insanity,  227 

Rod  ceUs,  182,  244 

Rolandic  area,  28 

Salicylate  delu'ium,  199 
Salvarsan  in  treatment,  184 
Sanguinity,  degree  of,  85 
Sanity,  and  insanity,  73 
certificate  of,  271 


342 


INDEX 


Scarlet  fever  and  insanity,  227 
Scavenger  cells,  244 
Schizophreuia,  157 
Scopolamine  in  treatment,  308 
Scotland,  lunacy  procedure  in,  277 
Seclusion  in  treatment,  274,  298 
Secondary  dementia,  163 

sensations,  37 

Sections,  preparation  of,  236 
Sedatives  in  treatment,  306 
Seduction  as  a  cause,  97 
Seizures,  congestive,  175 
Self,  16 

Senile  dementia,  167 
SeniUty,  95,  207 
Sensation,  31 

after,  37 

disorders  of,  34 

epigastric,  39 

organic,  33 

physical  substratum  for,  33 

recurrent,  37 

secondary,  37 

• special,  32 

Sensory  areas,  28,  33 
Sentiments,  52 

disorders  of,  53 

physical  basis  of,  53 

Septicsemia,  94,  227 
Sex,  incidence  of,  1 

prognosis  in,  257 

Sexual  excess,  95.  132,  173 

hypochondriasis,  110,  140 

inversion,  60,  96,  138,  155 

perversion,  vide  Masturbation 

precocity,  148,  154 

Shock  as  a  cause,  98 

Sight,  32 

Signs,  local,  35 

Sin,  the  unpardonable,  43,  107 

Single  care,  273,  292,  294 

Sinuses  of  the  brain,  248 

Skin  affections  in  the  insane,  232 

sensation,  33 

Slander  by  the  insane,  281 
Sleep,  18 

chart  showing  daily  amount  of,  21 

disorders  of,  20 

intensity  of,  19 

physical  basis  of,  19 

Sleeplessness,  vide  Insomnia 

Smallpox  and  insanity,  227 

Smell,  33 

Social  influences  in  treatment,  317 

Solitude  as  a  cause,  98 

Space  perception,  35 

Special  sensation,  32 

Speech,  55,  63,  64 

disorders  of,  65 

Spider  cells,  182,  244 
Stage  fright,  224 


Stages  of  general  paralysis,  178 
Staining  processes,  22,  242,  244 
Stammering,  65 
Statement  for  mental  deficiency,  275 

of  particulars,  266,  326 

—  of  urgency,  269,  332 
Static  perception,  35 

sensation,  33 

Status  epilepticus,  210 

Stereognosis,  35 

Stereotypy,  162 

Sterility,  96 

Stigmata   of    deeeneracy,  88,  91,    137, 

147,  210,  254  " 
Strait-jacket,  274,  298 
Stress,  91 

direct,  92 

environmental,  96 

indirect,  94 

Stupor,  132 

katatonic,  158 

varieties  of,  133 

Subconsciousness,  17 
Suggestibility,  64,  160,  178,  218 
Suggestion,  treatment  by,  314 
Suicidal  intentions,  treatment  of,  304 
Suicide,  60,  285 

potential,  110 

Sulphonal  in  treatment,  307 

toxic  effects  of,  200 

Summary  reception  orders,  264,  333 

Sunstroke  and  insanity,  94,  232 

Supersedeas,  271 

Surgical  operations  on  the  insane,  311 

Suspicion,  49,  139,  192 

Symbolism,  138 

Synapses,  23,  243 

SyphiUs  and  insanity,  93,  166,  172,  228 

Syphilophobia,  224,  228 

Systematised  delusional  insanity,  136 

Tabes  dorsalis  and  insanity,  228 
Taste,  32 
Temperament,  48 
Temperature  in  insanity,  71 
Terminal  dementia,  163 
Testamentary  capacity,  278 
Thalamus,  function  of,  34,  48 
Theft,  154,  224,  284 
Thought,  39 
Three-day  order,  264 
Thyroid,  diseases  of,  229 

treatment,  310 

Tics,  223 

Time  perception,  35 

Tobacco,  influence  of,  289,  318 

Tone  of  feeling,  47,  48,  69 

Toucher,  folic  du.  65 

Toxic  insanity,  125 

Toxins,  92,  243 

Train  of  thought,  40,  41 


INDEX 


343 


Transfer  of  patients,  274,  276 
Transference  of  affects,  52,  225 
Traumatic  neurasthenia,  217,  221,  234 
Traumatism  and  insanity,  94,  233 
Travel,  112,  141,  222,  292,  318 
Treatment,  curative,  291 

general,  286 

Treatment,  mental  and  moral,  313 

preventive,  286 

thyroid,  310 

Trespass  by  the  insane,  281 
Trional  in  treatment,  307 
Trophic  centres  in  cortex,  16 

changes  in  insanity,  82,  176,  255 

Truth,  52 

Tube  feeding,  301,  302 

Tubercle  in  insanity,  96,  228 

Unconsciousness,  17 
Urethane  in  treatment,  308 
Urgency  certificate,  269,  331 

order,  269,  329 

statement,  269,  330,  332 

Urine  in  insanity,   106,   176,   189,   203, 
217,  221 

Vaccmes  in  insanity,  310 

Vacuolation,  242 

Varieties  of  Dementia  Prajcox,  157 

general  paralysis,  179 

idiocy,  144 


Varieties  of  stupor,  133 
Venous  sinuses  of  brain,  248 
Verbigeration,  43,  160 
Veronal  in  treatment,  307 
Violence,  treatment  of,  298,  308 
Virtues,  52 

Visitors,  Lord  Qiancellor's,  272 
Volition,  61 

disorders  of,  63 

Volitional  insanity,  223 
Voluntary  boarders,  272 

Wandering  lunatics,  265 
Wassermann  reaction,  246 
Weber-Fechner  law,  31 
Weight  of  brain,  237 
Weir-aiitchell  treatment,  222 
Weissmann's  theory  of  inheritance,  87 
Wet  pack,  274,  299 
Wm,  61 

making  a,  278 

physical  basis  of,  62 

Witnesses,  the  insane  as,  282 
Witselsucht  (or  Moria),  166 
Word  associations,  315 

bHndness,  36 

deafness,  36 

Workhouses,  insane  in,  265 
Worry  as  a  cause,  96 
Writing,  55,  63,  64 
disorders  of,  65,  66,  192 


PRINTED    I'OK   THE    CXIVERSITY   OF   LONDON   PRESS,   LTD.,   BY 

EICHAED    CLAY    &    SONS,  LIMITED, 

LONDON   AND   BUNGAY. 


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